Section Editors: Steven K.

Libutti, MD, FACS

Chief
A. Alfred Chahine, MD, FACS Tumor Angiogenesis Section
Associate Professor of Surgery and Pediatrics Surgery Branch, National Cancer Institute
The George Washington University School of Medicine Professor of Surgery
Program Director Uniformed Services University of the Health Sciences
General Surgery Residency Bethesda, Maryland
Georgetown University Medical Center
Washington, DC M. Blair Marshall, MD, FACS
Associate Professor of Surgery
Edward E. Cornwell III, MD, FACS, FCCM Georgetown University School of Medicine
LaSalle D. Leffall Jr Professor Chief
Chairman of Surgery Division of Thoracic Surgery
Howard University Hospital Department of Surgery
Washington, DC Georgetown University Medical Center
Washington, DC
Gerard M. Doherty, MD
NW Thompson Professor of Surgery Leigh A. Neumayer, MD, MS
University of Michigan Professor of Surgery
Head University of Utah School of Medicine
Section of General Surgery Huntsman Cancer Institute
University of Michigan Health System Salt Lake City, Utah
Ann Arbor, Michigan
Richard F. Neville, MD
Eugene F. Foley, MD Chief
Professor of Surgery Division of Vascular Surgery
Section of Colon and Rectal Surgery Medical Director
Department of Surgery Non-invasive Vascular Lab
University of Wisconsin School of Medicine and Georgetown University Hospital
Public Health Washington, DC
Madison, Wisconsin
Shawna C. Willey, MD, FACS
Lynt B. Johnson, MD, MBA Associate Professor
Professor Georgetown University
Georgetown University Director
Chief of Transplantation Surgery Betty Lou Ourisman Breast Health Center
Vice-Chairman Lombardi Comprehensive Cancer Center
Department of Surgery Washington, DC
Georgetown University Hospital
Washington, DC
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

Surgical pitfalls: prevention and management ISBN: 978-1-4160-2951-9

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Library of Congress Cataloging-in-Publication Data

Surgical pitfalls : an evidence-based approach to prevention and management / [edited by] Stephen R.T.
Evans ; section editors, A. Alfred Chahine . . . [et al.].1st ed.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-4160-2951-9
1. Surgical errors. I. Evans, Stephen R. T. II. Chahine, A. Alfred.
[DNLM: 1. Intraoperative Complicationsprevention & control. 2. Evidence-Based
Medicine. 3. Medical Errorsprevention & control. 4. Risk Factors. 5. Risk Management.
6. Surgical Procedures, Operativeadverse effects. WO 181 S961 2009]
RD27.85.S87 2009
617.9dc22 2008034840

Publishing Director: Judith Fletcher

Acquisitions Editor: Scott Scheidt
Developmental Editor: Sarah A. Myer
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To my loving wife Karen, who every day
fuels the re of love in my heart and
makes every moment together pure joy.
Stephen Evans, MD
Contributors

Christopher J. Abularrage, MD Sara A. Bloom, MD

Fellow in Vascular Surgery, Massachusetts General Chief Resident, Department of Surgery, Georgetown
Hospital, Boston, Massachusetts University Hospital, Washington, DC
Infrainguinal Revascularization Axillary Surgery
Reid B. Adams, MD Benjamin Braslow, MD
Professor of Surgery, Division Chief, Surgical Oncology, Assistant Professor of Surgery, University of Pennsylva-
and Chief, Hepatobiliary and Pancreatic Surgery, Univer- nia School of Medicine; Director of Emergency Surgical
sity of Virginia Health System, Charlottesville, Virginia Service, Hospital of the University of Pennsylvania,
Enterectomy Philadelphia, Pennsylvania
Damage Control: Abdominal Closures
Mark S. Allen, MD
Professor and Chair, Division of General Thoracic David A. Bruno, MD
Surgery; Consultant, Division of General Thoracic Chief Resident, Department of Surgery, Georgetown
Surgery, Mayo Clinic, Rochester, Minnesota University, Washington, DC
Pneumonectomy Resection and Reconstruction of the Biliary Tract
Stephen L. Altman, Esq, JD Joseph F. Buell, MD, FACS
Partner, Hamilton Altman Canale & Dillon, LLC, Professor of Surgery and Director of Transplantation,
Fairfax, Virginia University of Louisville, Louisville, Kentucky
Legal Considerations Laparoscopic Liver Resection
Rupen Amin, MD John Byrne, MB, BCh, BAO, MCh, FRCSI(Gen)
Research Fellow, Georgetown University School of Attending, Albany Medical Center Hospital, Albany,
Medicine, Washington, DC New York
Pancreaticoduodenectomy Aortic Surgery
Andrea Badillo, MD A. Alfred Chahine, MD, FACS
Resident in General Surgery, The George Washington Associate Professor of Surgery and Pediatrics, The
University, Washington, DC George Washington University School of Medicine;
Graham Patch Repair Program Director, General Surgery Residency,
Georgetown University Medical Center,
Catherine Bertram, JD
Washington, DC
Partner, Regan Zambri & Long, PLLC, Washington, DC
Imperforate Anus and Hirschsprungs Disease; Congenital
Legal Considerations
Diaphragmatic Hernia
Parag Bhanot, MD
David C. Chang, PhD, MPH, MBA
Assistant Professor of Surgery, Georgetown University
Assistant Professor of Surgery, Department of Surgery,
Hospital, Washington, DC
Johns Hopkins School of Medicine, Baltimore,
Open Inguinal Hernia Repair with Plug and Patch
Maryland
Technique; Laparoscopic Incisional Hernia Repair
Evaluating Trauma Literature
Joseph A. Blanseld, MD
Zandra Cheng, MD
Clinical Assistant Professor of Surgery, Temple
Breast Surgeon, Anne Arundel Medical Center Breast
University School of Medicine, Philadelphia; Associate,
Center, Annapolis, Maryland
Department of Surgical Oncology, Geisinger Medical
Breast Biopsy and Breast-Conserving Surgical
Center, Danville, Pennsylvania
Techniques
Isolated Limb Perfusions and Extremity Amputations
Mark D. Cipolle, MD, PhD, FACS
Kenneth J. Bloom, MD
Medical Director, Trauma Program, and Member of
Clinical Professor of Pathology, Keck School of Medicine;
Staff, General Surgery, Christiana Care Health System,
Chief Medical Ofcer, Clarient, Inc., Aliso Viejo, California
Wilmington, Delaware
Image-Guided Breast Biopsy
Central Vein Catheterization
 viii CONTRIBUTORS
Bryan M. Clary, MD
Associate Professor of Surgery, and Chief, Hepatobiliary
Surgery, Duke University Medical Center, Durham,
North Carolina
Trisectionectomy
Edward E. Cornwell III, MD, FACS, FCCM
LaSalle D. Leffall Jr Professor and Chairman of Surgery,
Howard University Hospital, Washington, DC
Management of Thoracic Trauma; Management of
Pancreatic and Duodenal Injuries; Traumatic Brain
Injury; Managing Injuries to the Spleen
Derrick D. Cox, MD
Chief Resident, General Surgery, Georgetown
University Hospital, Washington, DC
Open Inguinal Hernia Repair with Plug and Patch
Technique
Aimee M. Crago, MD, PhD
Fellow, Surgical Oncology, Memorial Sloan Kettering
Cancer Center, New York, New York
Preoperative Pitfalls; Gastrectomy with Reconstruction
Dale A. Dangleben, MD
Assistant Program Director, General Surgery Residency,
and Member of Staff, General Surgery, and Trauma/
Surgical Critical Care, Lehigh Valley Hospital,
Allentown, Pennsylvania
Central Vein Catheterization
R. Clement Darling III, MD
Professor of Surgery, Albany Medical College; Chief,
Division of Vascular Surgery, Albany Medical Center
Hospital, Albany, New York
Aortic Surgery
Elizabeth A. David, MD
Resident, General Surgery, Georgetown University
Hospital, Washington, DC
Arterial Catheterization; Laparoscopic Nissen
Fundoplication
James E. Davies, MD
Assistant Professor, Department of Cardiothoracic
Surgery, University of Iowa, Iowa City, Iowa
Pneumonectomy
David Deaton, MD
Assistant Professor, Georgetown University; Chief of
Endovascular Surgery, Division of Vascular Surgery,
Department of Surgery, Georgetown University
Hospital, Washington, DC
Endovascular Interventions
Demetrios Demetriades, MD, PhD
Professor of Surgery, University of Southern California
School of Medicine; Director of Trauma and Critical
Care, Los Angeles County and University of Southern
California Medical Center, Los Angeles, California
Management of Penetrating Neck Injury
Kiran K. Dhanireddy, MD
Transplant Fellow, UCLA Medical Center, Los Angeles,
California
Distal Pancreatectomy
Gerard M. Doherty, MD
NW Thompson Professor of Surgery, University of
Michigan; Head, Section of General Surgery, University
of Michigan Health System, Ann Arbor, Michigan
Thyroid Surgery
Jessica S. Donington, MD
Assistant Professor, Department of Cardiothoracic
Surgery, New York University, New York, New York
Chest Wall Resections
Brian J. Duffy, MD
The George Washington University; Research Fellow,
Childrens National Medical Center, Washington, DC
Pectus Excavatum
Quan-Yang Duh, MD
Professor of Surgery, University of California, San
Francisco; Attending Surgeon, Veterans Affairs Medical
Center, San Francisco, California
Laparoscopic Inguinal Hernia Repair
David T. Efron, MD
Assistant Professor of Surgery, Johns Hopkins School of
Medicine; Director of Trauma, Division of Acute Care
Surgery: Trauma, Critical Care, Emergency and General
Surgery, The Johns Hopkins Hospital, Baltimore,
Maryland
Management of Thoracic Trauma; Management of
Pancreatic and Duodenal Injuries
Martin R. Eichelberger, MD
Professor of Surgery and Pediatrics, The George
Washington University; Attending Surgeon, Childrens
National Medical Center, Washington, DC
Pectus Excavatum
Rebecca Evangelista, MD
Assistant Professor of Surgery, Georgetown University
Medical Center; Staff Surgeon, Veterans Affairs Medical
Center, Washington, DC
Open Gastrostomy Feeding Tube Placement and
Percutaneous Endoscopic Gastrostomy Tube Placement;
Open Jejunostomy Tube Placement
Stephen R. T. Evans, MD, FACS
Robert J. Coffey Professor and Chairman, Department
of Surgery, Georgetown University Medical Center,
Washington, DC
From Error to Perfection: The Process of Surgical
Maturation; Teaching Technical SkillsErrors in the
Process; Preoperative Pitfalls; Arterial Catheterization;
Chest Tube Insertion; Paracentesis; Laparoscopic Nissen
Fundoplication; Laparoscopic Esophagomyotomy with Dor
Fundoplication; Gastrectomy with Reconstruction
 CONTRIBUTORS ix

Eleanor Faherty, MD Kelly Garrett, MD

Staff Surgeon, and Captain, United States Air Force, Chief Resident, Albany Medical College, Albany, New York
Malcolm Grow Medical Center, Andrews Air Force Left Colectomy: Open and Laparoscopic
Base, Maryland
Ankur Gosalia, MD
Open Gastrostomy Feeding Tube Placement and
Assistant Professor of Anesthesiology, Temple
Percutaneous Endoscopic Gastrostomy Tube Placement;
University, Philadelphia; Attending Anesthesiologist,
Open Jejunostomy Tube Placement; Lateral
Western Pennsylvania Hospital, Pittsburgh, Pennsylvania
Pancreaticojejunostomy (Puestow) Procedure;
Anesthesia for the Surgeon
Supraclavicular Lymph Node Biopsy
Vicente H. Gracias, MD
Elizabeth D. Feldman, MD
Associate Professor of Surgery, and Chief, Surgical
Assistant Professor, Georgetown University,
Critical Care, University of Pennsylvania School of
Washington, DC
Medicine, Philadelphia, Pennsylvania
Mastectomy
Damage Control: Abdominal Closures
Felix G. Fernandez, MD
Jay A. Graham, MD
Cardiothoracic Fellow, Barnes-Jewish Hospital, Washington
Resident, Department of Surgery, Georgetown
University School of Medicine, St. Louis, Missouri
University, Washington, DC
Thymectomy and Resection of Mediastinal Masses
Laparoscopic Surgery; Right Hepatectomy; Left Hepatectomy
Richard E. Fine, MD
Philip C. Guzzetta, Jr., MD
Clinical Associate Professor, Department of Surgery,
Professor of Surgery and Pediatrics, The George
University of Tennessee College of Medicine
Washington University; Pediatric Surgery Chief Resident
Chattanooga Unit, Chattanooga, Tennessee; Director,
Program Director, Childrens National Medical Center,
Breast Care Continuum Program, Wellstar Kennestone
Washington, DC
Hospital, Marietta, Georgia
Malrotation, Volvulus, and Bowel Obstruction
Image-Guided Breast Biopsy
Adil H. Haider, MD, MPH
Thomas M. Fishbein, MD
Assistant Professor of Surgery, Division of Trauma/
Professor, Department of Surgery, Georgetown
Critical Care, Johns Hopkins School of Medicine,
University; Director of Small Bowel and Pediatric Liver
Baltimore, Maryland
Transplant Program, Georgetown University Hospital,
Traumatic Brain Injury; Managing Injuries to the Spleen
Washington, DC
Distal Pancreatectomy; Resection and Reconstruction of Elliott R. Haut, MD, FACS
the Biliary Tract Assistant Professor of Surgery and Anesthesiology and
Critical Care Medicine, Division of Acute Care Surgery:
James FitzGerald, MD
Trauma, Critical Care, Emergency and General Surgery,
Attending Surgeon, Washington Hospital Center,
Department of Anesthesiology and Critical Care
Washington, DC
Medicine, Johns Hopkins School of Medicine; Director,
Ileostomy
Trauma / Acute Care Surgery Fellowship, The Johns
Eugene F. Foley, MD Hopkins Hospital, Baltimore, Maryland
Professor of Surgery, Section of Colon and Rectal Evaluation and Acute Resuscitation of the Trauma Patient
Surgery, Department of Surgery, University of
Mary Hawn, MD, MPH
Wisconsin School of Medicine and Public Health,
Associate Professor of Surgery, and Chief, Section of
Madison, Wisconsin
Gastrointestinal Surgery, University of Alabama at
Hemorrhoidectomy; Anal Fistulotomy
Birmingham, Birmingham, Alabama
Hugh M. Foy, MD Open Primary and Mesh Repairs
Professor of Surgery, and Head, Wind River College,
Richard F. Heitmiller, MD
University of Washington School of Medicine;
Associate Professor of Surgery, Johns Hopkins Medical
Attending Surgeon, Harborview Medical Center,
Institutions; J.M.T. Finney Chairman of Surgery, Union
Seattle, Washington
Memorial Hospital, Baltimore, Maryland
Teaching Technical SkillsErrors in the Process
Esophageal Surgery
Charles M. Friel, MD
Earl Hodin, MD
Associate Professor of Surgery, and Chief, Section of
Attending Surgeon, Childrens National Medical Center,
Colon and Rectal Surgery, University of Virginia,
Washington, DC, and Inova Fairfax Hospital, Falls
Charlottesville, Virginia
Church, Virginia
Low Anterior Resection; Abdominal Perineal Resection
Inguinal and Umbilical Hernias
with Colostomy
 x CONTRIBUTORS
Arsalla Islam, MD
Assistant Instructor, GI Endocrine Surgery Division,
Department of Surgery, University of Texas
Southwestern Medical Center, Dallas, Texas
Adrenal Surgery
Kamal M. F. Itani, MD
Professor of Surgery, Boston University School of
Medicine; Chief of Surgery, Veterans Affairs Boston
Healthcare System, Boston, Massachusetts
Umbilical and Epigastric Hernias
Patrick G. Jackson, MD
Associate Residency Program Director, Georgetown
University; Assistant Professor of Surgery, Georgetown
University Hospital, Washington, DC
Laparoscopic Surgery; Vagotomy and Pyloroplasty; Lateral
Pancreaticojejunostomy (Puestow) Procedure; Pancreatic
Cyst/Debridement
Lynt B. Johnson, MD, MBA
Professor, Georgetown University; Chief of Transplanta-
tion Surgery, and Vice-Chairman, Department of Surgery,
Georgetown University Hospital, Washington, DC
Right Hepatectomy; Left Hepatectomy;
Pancreaticoduodenectomy; Pancreatic Cyst/Debridement
Benjamin Kim, MD
Staff Physician, Kaiser Permanente West Los Angeles
Medical Center, Los Angeles, California
Laparoscopic Inguinal Hernia Repair
Lawrence T. Kim, MD, FACS
Professor, Department of Surgery, University of
Arkansas for Medical Sciences; Chief, Surgical Service,
Central Arkansas Veterans Healthcare System, Little
Rock, Arkansas
Parathyroid Surgery
Daniel Kreisel, MD, PhD
Assistant Professor of Surgery, Pathology and
Immunology, Washington University in St. Louis,
St. Louis, Missouri
Thymectomy and Resection of Mediastinal Masses
John C. Kucharczuk, MD
Assistant Professor of Surgery, University of
Pennsylvania School of Medicine; Division of Thoracic
Surgery, Hospital of the University of Pennsylvania,
Philadelphia, Pennsylvania
Bronchoscopy: Flexible and Rigid; Esophagoscopy: Flexible
and Rigid; Mediastinoscopy; and Anterior
Mediastinotomy
Paul C. Kuo, MD, MBA
Professor of Surgery, and Chief, Division of General
Surgery, Duke University Medical Center, Durham,
North Carolina
Trisectionectomy
James Laredo, MD
Assistant Professor, Division of Vascular Surgery,
Department of Surgery, Georgetown University;
Georgetown University Hospital, Washington, DC
Venous Surgical Pitfalls
David W. Larson, MD
Consultant in Surgery and Assistant Professor of
Surgery, Mayo Clinic, Mayo Medical School, Rochester,
Minnesota
Right Colectomy: Open and Laparoscopic
Edward C. Lee, MD, FACS, FASCRS
Associate Professor of Surgery, Chief, Section of GI/
Surgical Oncology, and Vice Chairman for Clinical
Affairs, Albany Medical College, Albany,
New York
Left Colectomy: Open and Laparoscopic
Stacy Loeb, MD
Resident in Training (Urology), Johns Hopkins Medical
Institutions, Baltimore, Maryland
Paracentesis
Amy D. Lu, MD, MPH, MBA
Associate Professor of Surgery, Albert Einstein College
of Medicine; Director, Renal Transplant Program,
Monteore Medical Center, Bronx, New York
Gallbladder: Cholecystectomy (Laparoscopic vs. Open)
Jeffrey Lukish, MD
Associate Professor of Surgery and Pediatrics,
and Chief, Division of Pediatric Surgery, Uniformed
Services University of the Health Sciences,
Bethesda, Maryland
Tracheoesophageal Fistula and Esophageal
Atresia Repair
Robyn A. Macsata, MD
Chief, Vascular Surgery, Veterans Affairs Medical
Center, Washington, DC
Arteriovenous Hemodialysis Access
Donna-Marie Manasseh, MD
Co-Director of the Womens Breast Health Center,
Stamford Hospital Foundation, New Haven,
Connecticut
Axillary Surgery
Carlos E. Marroquin, MD
Assistant Professor of Surgery, Duke University Medical
Center, Durham, North Carolina
Trisectionectomy
M. Blair Marshall, MD, FACS
Associate Professor of Surgery, Georgetown University
School of Medicine; Chief, Division of Thoracic
Surgery, Department of Surgery, Georgetown University
Medical Center, Washington, DC
Bronchial and Vascular Sleeve Lobectomy

Marga F. Massey, MD, FACS
Associate, Center for Microsurgical Breast
Reconstruction, Charleston/Chicago/Salt Lake City,
Charleston, South Carolina
Component Separation for Complex Abdominal Wall
Reconstruction and Recurrent Ventral Hernia Repair
Aarti Mathur, MD
Resident in Surgery, Georgetown University,
Washington, DC
Chest Tube Insertion; Laparoscopic Splenectomy
Fabio May da Silva, MD
Professor of Clinical Surgery, Universidade do Sul de
Santa Catarina; Thoracic Surgeon, Secretaria do Estado
de Santa Catarina, Florianopolis, Santa Catarina, Brazil
Bronchial and Vascular Sleeve Lobectomy
Michael McLeod, MD
Associate Professor, Michigan State University,
Kalamazoo, Michigan
Thyroid Surgery
Aziz Merchant, MD
Fellow, Minimally Invasive Surgery, Emory University,
Atlanta, Georgia
Pyloromyotomy
Angela M. Mislowsky, MD
Chief ResidentSurgery, Union Memorial Hospital,
Baltimore, Maryland
Esophageal Surgery
Bruno Molino, MD
Director, Division of Trauma, Liberty HealthJersey
City Medical Center, Jersey City, New Jersey
Damage Control: Abdominal Closures
Gitonga Munene, MD
Chief Resident Physician, Georgetown University
Hospital, Washington, DC
Gastrectomy with Reconstruction
Russell J. Nauta, MD, FACS
Professor of Surgery, Harvard Medical School; Vice-
Chairman, Surgery, Beth Israel-Deaconess Medical
Center; Chairman of Surgery, Mount Auburn Hospital
and Harvard Health Services, Cambridge, Massachusetts
General Laparotomy
Edward W. Nelson, MD
Professor of Surgery and Division Chief of General
Surgery, University of Utah School of Medicine,
Salt Lake City, Utah
Prolene Hernia SystemHernia Repair
Richard F. Neville, MD
Chief, Division of Vascular Surgery, and Medical
Director, Non-invasive Vascular Lab, Georgetown
University Hospital, Washington, DC
Carotid Endarterectomy; Infrainguinal
Revascularization
CONTRIBUTORS xi
Kurt D. Newman, MD
Professor of Surgery and Pediatrics, The George
Washington University School of Medicine; Surgeon in
Chief, and Executive Director, Joseph E. Robert, Jr.
Center for Surgical Care, Childrens National Medical
Center, Washington, DC
Pyloromyotomy
C. Joe Northup, MD, FACS
Assistant Professor, University of Virginia Health
System, Charlottesville, Virginia
Laparoscopic Appendectomy
Fiemu Nwariaku, MD, FACS, FWACS
Malcolm O. Perry MD Professor, and Associate Professor
and Vice Chair, Department of Surgery, University of
Texas Southwestern Medical Center, Dallas, Texas
Adrenal Surgery
Michael D. Pasquale, MD, FACS, FCCM
Associate Professor of Surgery, Penn State College of
Medicine, Penn State University, Hershey; Senior Vice
Chair, Department of Surgery, Chief, Division of
Trauma/Surgical Critical Care, and Member of Staff,
General Surgery, and Trauma/Surgical Critical Care,
Lehigh Valley Hospital, Allentown, Pennsylvania
Central Vein Catheterization; Pulmonary Artery
Catheterization
James F. Pingpank, Jr., MD
Head, Surgical Metabolism Section, Surgery Branch,
National Cancer Institute, National Institutes of Health,
Bethesda, Maryland
Isolated Limb Perfusions and Extremity Amputations
Dahlia Plummer, MD
Vascular Fellow, Georgetown University, Washington, DC
Carotid Endarterectomy
Todd A. Ponsky, MD
Assistant Professor of Surgery, Case Western Reserve
University; Assistant Professor of Surgery, Division of
Pediatric Surgery, Rainbow Babies and Childrens
Hospital, Cleveland, Ohio
Wilms Tumor and Neuroblastoma
David M. Powell, MD
Associate Professor of Surgery and Pediatrics, The
George Washington University; Attending Surgeon,
Childrens National Medical Center, Washington, DC
Pectus Excavatum
Brian Reuben, MD
Chief Resident, General Surgery, University of Utah,
Salt Lake City, Utah
Component Separation for Complex Abdominal Wall
Reconstruction and Recurrent Ventral Hernia Repair
T. A. Rothenbach, MD
Staff Surgeon, Pediatric Surgery Inc., The Childrens
Hospital at Saint Francis, Tulsa, Oklahoma
Congenital Diaphragmatic Hernia
 xii CONTRIBUTORS
Shawn D. Safford, MD
Assistant Professor of Surgery, Uniformed Services
University of the Health Sciences, Bethesda, Maryland
Tracheoesophageal Fistula and Esophageal Atresia Repair
Ali Salim, MD
Program Director, General Surgery Residency, Cedars-
Sinai Medical Center, Los Angeles, California
Management of Penetrating Neck Injury
Rovinder S. Sandhu, MD, FACS
Clinical Assistant Professor of Surgery, Penn State
College of Medicine, Penn State University, Hershey;
Medical Director, Adult Transitional Trauma Unit, and
Member of Staff, General Surgery, and Trauma/Surgical
Critical Care, Lehigh Valley Hospital, Allentown,
Pennsylvania
Central Vein Catheterization; Pulmonary Artery
Catheterization
Babak Sarani, MD
Assistant Professor of Surgery, University of
Pennsylvania; Attending Surgeon, Division of
Traumatology, Emergency Surgery, and Surgical Critical
Care, Hospital of the University of Pennsylvania,
Philadelphia, Pennsylvania
Anesthesia for the Surgeon; Graham Patch Repair
John E. Scarborough, MD
Assistant Professor of Surgery, Department of Surgery,
Duke University Medical Center, Durham, North Carolina
Trisectionectomy
Bruce Schirmer, MD
Stephen H. Watts Professor of Surgery, University of
Virginia Health System, Charlottesville, Virginia
Laparoscopic Gastric Bypass
Joseph B. Shrager, MD
Professor of Cardiothoracic Surgery, Stanford University
School of Medicine, Stanford; Chief, Division of
Thoracic Surgery, Stanford University Hospital,
Stanford; Staff Surgeon, Palo Alto Veterans Affairs
Health Care System, Palo Alto, California
Cervical Tracheal Resection and Reconstruction
Anton N. Sidawy, MD, MPH
Professor of Surgery, Georgetown and George Washington
University Schools of Medicine; Chief, Surgical Service,
Veterans Affairs Medical Center, Washington, DC
Arteriovenous Hemodialysis Access
Niten Singh, MD
Assistant Professor of Surgery, Uniformed Services
University of the Health Sciences, Bethesda, Maryland;
Chief, Endovascular Surgery, Madigan Army Medical
Center, Tacoma, Washington
Venous Surgical Pitfalls; Endovascular Interventions
William H. Snyder, MD
Professor of Surgery, Department of Surgery, University
of Texas Southwestern Medical Center, Dallas, Texas
Adrenal Surgery
Scott J. Swanson, MD
The Eugene W. Friedman Professor of Surgical
Oncology, Mount Sinai School of Medicine; Chief,
Division of Thoracic Surgery, Mount Sinai Medical
Center, New York, New York
Lobar Resections
Lorraine Tafra, MD
Director, The Breast Center, Anne Arundel Medical
Center, Annapolis, Maryland
Breast Biopsy and Breast-Conserving Surgical Techniques
Amit D. Tevar, MD, FACS
Assistant Professor, University of Cincinnati, Cincinnati, Ohio
Laparoscopic Liver Resection
Mark J. Thomas, MD
Assistant Professor, University of Cincinnati, Cincinnati, Ohio
Laparoscopic Liver Resection
Trevor Upham, MD
Surgical Resident, Department of Surgery, Georgetown
University Hospital, Washington, DC
Pancreatic Cyst/Debridement
Daniel Vargo, MD
Associate Professor of Surgery, Division of General
Surgery, Department of Surgery, University of Utah,
Salt Lake City, Utah
Component Separation for Complex Abdominal Wall
Reconstruction and Recurrent Ventral Hernia Repair
Diana M. Weber, MD
Surgeon, Presbyterian Hospital, Albuquerque, New Mexico
Laparoscopic Splenectomy; Supraclavicular Lymph
Node Biopsy
Todd S. Weiser, MD
Assistant Professor, Mount Sinai School of Medicine;
Attending, Mount Sinai Medical Center, New York,
New York
Lobar Resections
Tamica White, MD
Thoracic Surgeon, Surgical Specialists of North Jersey,
Englewood, New Jersey
Vagotomy and Pyloroplasty
Shawna C. Willey, MD, FACS
Associate Professor, Georgetown University; Director,
Betty Lou Ourisman Breast Health Center, Lombardi
Comprehensive Cancer Center, Washington, DC
Mastectomy
Alexander Wohler, MD
Fellow in Cardiothoracic Surgery, Mount Sinai Medical
Center, New York, New York
Laparoscopic Esophagomyotomy with Dor Fundoplication
James C. Yang, MD
Assistant Professor, Uniformed Services University of
the Health Sciences; Senior Investigator, Surgery
Branch, National Cancer Institute, National Institutes of
Health, Bethesda, Maryland
Management of Soft Tissue Sarcoma
Preface
It is on our failures that we base a new and different and better success.
Havelock Ellis
As a profession, surgeons are exceedingly reluctant to
publicize our errors. Whether they are errors in judgment
or intraoperative technical errors, they are usually kept to
ourselves or become semi-public when presented formally
at the usual Morbidity and Mortality conferences held
weekly at all hospitals by surgeons throughout the country.
It is quite clear, however, that the Morbidity and Mortal-
ity conference proves to be the most educationally pro-
ductive conference for all surgeons because of how much
we learn from our own errors as well as the errors of
others.
Surgical Pitfalls has been a work in progress for many
years and is targeted not just at surgeons in training but
at surgeons of all levels of expertise. Our hope is that this
will lead to signicant error prevention and improve and
enhance error training through surgical residencies. We
have therefore constructed this book to include all of the
major specialties in surgery.
This book is unique in its intent to identify intraopera-
tive errors that occur at specic steps during both simple
and complex operations, but more importantly identifying
how to prevent the error, the consequences of the error
if they occur, and lastly, how to repair or correct the error
once it has happened. The book covers over 80 major
operative procedures in addition to discussing common
errors, especially errors in preoperative decision making
based upon individual organ systems and risk stratication
that should be considered in preoperative assessment and
evaluation of all patients. Additionally, errors made in
teaching technical skills are reviewed, errors in communi-
cation that lead to medical legal issues, and lastly an over-
view in the introductory section on the process of surgical
maturation.
During this rst edition we have attempted to be as
comprehensive as possible in describing all major pub-
lished intraoperative complications and intraoperative
errors that are made in our decision making. As previously
stated, however, surgeons are reluctant not just to talk
about our mistakes, but certainly loathe publishing
them. In preparation for our second edition we are actively
soliciting cases with substantial intraoperative or radio-
graphic conrmation and documentation of the specic
errors and complications that have occurred with the
intent of making the second edition even more compre-
hensive and truly an Encyclopedia of Error or the
Textbook of Morbidity and Mortality.
I would like to thank all of our extremely talented con-
tributing authors for their tremendous time and effort put
in to this rst edition. It is certainly much easier to write
an operative procedures textbook on how to do an oper-
ation; it is far more difcult to write a procedures manual
on how NOT to do an operation. I greatly thank our
contributors for their patience as we moved through this
sometimes arduous process. We have adhered to a tem-
plate which we hope that the reader will nd exceedingly
useful and user-friendly. In addition to our contributing
authors I would like to extend a heartfelt thanks to our
staff at Elsevier, including Scott Scheidt, Sarah Myer, and
our publishing director, Judy Fletcher. They have shared
the passion, excitement and energy that we all have for
this rst edition and have made the job all that much
easier.
Stephen R. T. Evans, MD, FACS
Introduction
Although the hospital course of a patient is affected pro-
foundly by what happens inside the operating room, many
complications can be prevented by adequate preoperative
preparation. Rates of postoperative myocardial infarction,
congestive heart failure, pneumonia, bleeding, and infec-
tion are all affected by identication of a patients indi-
vidual risk factors and medical optimization of the patients
condition prior to surgery. A clear history and physical
examination, reconciliation of a patients medication list,
and consultation with appropriate specialists are the rst
steps in ensuring that an operation will go as smoothly
as possible, and that hospital length of stay and preopera-
tive morbidity and mortality rates are maintained at a
minimum.
Complications
The grade of Complications is:
Grade 1Requires medical treatment only, i.e., antibiot-
ics for a urinary tract infection
Grade 2Requires a procedural intervention, i.e., percu-
taneous drainage of a pelvic abscess
Grade 3Requires reoperation, but without permanent
disability or removal of an organ
Grade 4Leads to a permanent disability, i.e., renal
failure requiring dialysis; or reoperation with organ
removal
Grade 5Death
Indications
The surgeon should complete a mental, if not physical,
checklist of preoperative risk factors and appropriate inter-
ventions for each patient who is scheduled for the operat-
ing room. There are no exceptions to this dictum. Even
in emergent situations, knowledge of the patients comor-
bidities should be elucidated as soon as possible to aid in
intraoperative and postoperative care.
Section I
GENERAL
CONSIDERATIONS
Stephen R. T. Evans, MD
An error the breadth of a single hair can lead one a thousand miles astray.
Chinese proverb

1
From Error to Perfection: The
Process of Surgical Maturation
Stephen R. T. Evans, MD

Mishaps are like knives that either serve us or cut us, as we
grasp them by the blade or the handle.James Russell
Lowell
SURGICAL ERRORS
Who Is to Blame?
The landmark report, To Err Is Human, from the Institute
of Medicine (IOM) published in 19991 spurred enormous
attention and focus on patient safety. Initiatives to reduce
the number of preventable deaths from medical errors
have received widespread awareness, both in the medical
literature and in the lay press.1 Five years after the IOM
report, Leape and Berwick published a grim account on
the lack of progress that the medical community has made
in enhancing patient safety.2 These authors urged the
medical community to take ownership in the matter and
said, We will not become safe until we chose to become
safe.2
Despite this pessimistic view, a few reports of improve-
ment have been published over the last several years.
Brennen3 demonstrated this more optimistic viewpoint.
He showed that the rate of injury in medical care in
the 1970s was 4.6% in the state of California, but by
1984, New Yorks rate declined to 3.7%, and by 1992,
Colorados and Utahs rates fell to 2.9%. In addition,
he reiterated what has long been known: that major
 2 SECTION I: GENERAL CONSIDERATIONS

operative procedures in cardiac surgery and neurosurgery individual in an attempt to improve error reduction at both
have shown signicant reductions in complication rates the cognitive and the technical levels. We also hope to
and overall mortality over the last several decades.3 affect the future of surgical education by exposing practical
Although at times met by some degree of animosity, ways to teach not just the surgical resident but also more
the Joint Commission on Accreditation of Healthcare experienced surgeons on the approach to error reduction
Organizations (JCAHO) and the Agency for Health Care on a daily basis. We hope that by looking carefully at aws
Research and Quality have certainly taken ownership in in cognitive thought processes or technical errors that are
developing policies to reduce medical errors on a national preventable, the opportunities for improvement at the
level. They have mandated error reduction policies in the practicing physician level will become obvious.
operating room such as preoperative checklists, surgical
marking for correct side and correct patient, and the
The Paralysis of Fear
obligatory timeout to enhance communication in the
operating room. These JCAHO policies are touted to Leape4 talked about the powerful fear of error (Fig. 11).
minimize errors by enhancing communication between This trilogy is encompassed by (1) the fear of embarrass-
anesthesia, nursing, and surgical staff. ment by colleagues, (2) the fear of patient reaction to
errors, and (3) the fear of litigation. It has seemingly
paralyzed our ability to proactively approach error reduc-
Taking Ownership
tion. Moreover, these collective fears are certainly the
At the individual practitioner level, signicant room for reasons why we have not uniformly shared and/or pub-
improvement still exists because we have not uniformly lished our complications.
chosen to become safe. This is because the surgical First, we loathe exposing our ignorance or technical
approach has historically been more reactive than proac- failures to our fellow surgeons and medical colleagues. To
tive. Although we, as surgeons, have a strong history of become the talk of the surgeons lounge over a recent
dissecting our own craft, evaluating successes and review- operative failure is our worst nightmare.
ing aws in forums such as morbidity and mortality Second, we face the fear of patient reaction to the
(M&M) conferences, we have not acted cohesively. mistake we made. It is natural to be uncomfortable talking
We all know that the surgical M&M conferencein to patients after mistakes and errors have occurred. Even
which surgeons tend to be honest and open about mis- more distressing is working in an academic health center
takes and propose to learn from those mistakeshas been where resident training is conducted and a mistake occurs.
hailed as the best educational experience for all trainees. Patients may commonly ask, What is the residents role
However, this forum can be disorganized and happen- in my operation and in my care? And if a mistake occurs,
stance and could become more word of mouth than the patient may ask, Is this is an error caused by the
anything reportable. Indeed, many other elds of medi- resident? or Is this a training error?
cine do not even participate in a weekly M&M conference. Lastly, the prevailing fear of litigation may have
Moreover, even when we know that errors are denable become the most dominant stagnating force we face. The
and predictable in given operations, our ability to educate
and train in error reduction has fallen short. Passionate
discussions that may surface in each hospitals lecture hall
are often forgotten by the next week.
Why have we not developed a national registry to report
errors that are discovered in these surgical think tanks?
Why do we not have a monthly journal dedicated solely
to exploring these mistakes to better our eld? Many bar-
riers exist to open discussion of surgical errors at a national
level, not the least of which is the medicolegal climate.
Whereas a unied approach at error reduction seems
insurmountable, the current intense focus on patient
safety should drive this initiative. We cannot accept any-
thing less than the effort toward perfection. As Deming
stated, if we had to live with 99.9%, we would have: two
unsafe plane landings per day at OHare, 16,000 pieces
of lost mail every hour, 32,000 bank checks deducted
from the wrong bank account every hour (Deming, per-
sonal communication, November 1987). Our sophisti-
cated culture demands this effort.
It is time for the individual surgeon to take ownership
in this matter. This textbook focuses exclusively upon the Figure 11 Lucian Leape. (Courtesy of Lucian L. Leape, MD.)
 1 FROM ERROR TO PERFECTION: THE PROCESS OF SURGICAL MATURATION
MALPRACTICE MACHINE is on our radar screen
daily and has certainly been popularized on the Internet
at such sites as ghtingforyou.com. One can nd them.
common headlines such as Surgical errors are among the
most carefully regarded secrets in the medical industry.
The Paradox
Although it is a formidable, some say impossible, task, we
cannot be frozen by inaction in an attempt to strive for
perfection. Leape described this complex conict: the
paradox . . . that although the standard of medical practice
is perfectionerror-free patient careall physicians rec-
ognize that mistakes are inevitable.2
We know we are all human, but this is not an explana-
tion accepted by the media, the public, the insurance
companies, or malpractice lawyers.
THEORIES OF HUMAN
PERFORMANCE
Knowledge-, Rule-, and Skill-Based
Performances
To understand how human errors occur, we must rst
understand the theories behind human performance.
Rasmussen and Jensen5 have written extensively on the
concepts of human performance, which they divide into
three types: (1) knowledge-based, (2) rule-based, and
(3) skill-based.5 First, knowledge-based performance
occurs when we act on novel thought during new situa-
tions (e.g., this is the interns lifeall operations are new
to them and all patient scenarios on the wards are unique
to them). Second, ruled-based performance happens
when we develop solutions to problems dictated by stored
rulespatterns of behavior that occur based upon specic
situations (e.g., when we are presented with the unmistak-
able, discreet areolar plane while mobilizing a right colon,
we know our dissection can proceed expediently and
safely). Third, skilled-based performance refers to pat-
terns of thought and action that are unconscious or
preprogrammed. These are certainly the most common,
routine performances that we carry on a daily basis (e.g.,
driving a car on the same roads daily to work or an expe-
rienced surgeon performing his or her 500th inguinal
hernia repair).
Errors in Human Performance
Reason6 and Rasmussen and Jensen5 have classied errors
that can occur in each of these performance categories.
Knowledge-based errors happen when there is simply
a lack of experience or knowledge or a misinterpretation
of the problem. These commonly occur to either the
inexperienced surgeon or trainee who is on the steep end
of the learning curve and who encounters a novel clinical
3
situation. It is these knowledge-based errors that we hope
this book will clearly illuminate so that we can all avoid
Rule-based errors are categorized as misapplied exper-
tise. The wrong rule is chosen during problem solving.
This is commonly related to a misperception of the situ-
ation or misapplication of a rule that is understood but
not used correctly.
Lastly, skill-based errors are referred to as slips.
They occur when there is an unusual break in the routine
or lack of an additional check (or time out) so that we,
for example, operate on the wrong leg or on the wrong
patient or leave a malleable in the patient after laparotomy.
Interestingly, these are more likely to occur with physio-
logic conditions such as fatigue and psychological interfer-
ences such as boredom or frustration.
Which errors are the most common? Actually, slips, the
skill-based errors, are the most common because most of
our daily mental functioning is automatic. However, the
rate of error is higher with knowledge-based errors because
these typically occur on the steep part of the learning
curve.6 This books aim is to illuminate and expose pitfalls
and errors at all three levels and to change our perfor-
mance in surgery by focusing training and policy on error
reduction.
Perceptual Errors in the Operating
Room: Heuristics
Understanding the etiology and mechanism for technical
errors that occur in operative procedures is a generalized
theme throughout this textbook. In a highly referenced
and quoted article, Way and coworkers7 studied patients
with major bile duct injuries during laparoscopic chole-
cystectomy in order to determine the cause of the errors.
They classied each injury into three different groups:
(1) knowledge and decision making errors, (2) a lack of
technical skills, and (3) errors of perceptual input or a
misperception of the anatomy. The majority of the injuries
were of the third type. This variety of error mechanism is
based on the principle of heuristics. Heuristics are normal,
rapid, subconscious responses that work based upon sub-
jective or illusory contours or shapes. If you look at an
example such as the Kanizsa triangle (Fig. 12), you may
think you are seeing a white triangle surrounded by dark
circles. However, a white triangle is NOT actually present,
your mind merely constructs it from the backdrop of the
circles. The white triangle also appears to be brighter than
the surrounding area, but in fact, it is not.
As surgeons, we have all encountered heuristics in some
way or another. Interestingly, it is inherent in the way our
brain functions. Our brain is wired to use the rst informa-
tion that comes to mind in order to understand or com-
prehend the world.
Heuristics are important to recognize, especially in
the setting of the operating room. As we proceed through
a common operation and visualize globally what the
 4 SECTION I: GENERAL CONSIDERATIONS
HEURISTICS
Imagery
The tendency to use the first
information that comes to mind
Fooling the mind
Figure 12 Kanizsa triangle. (From Way LW, Stewart L, Gantert
W, et al. Causes and prevention of laparoscopic bile duct injuries.
Ann Surg 2003;237:460469.)
operative eld looks like, we may have a tendency to
become complacent about what we see. Humans prefer
common patterns and familiarity, especially in the operat-
ing room. Therefore, we seek out what we already know
from memory. Making a rapid decision based only on
misrepresented visual input could get us in trouble. This
book will hopefully open our minds to the hidden anatomy
that we must all be cognizant of to prevent technical
errors.
As Reason6 described, the price we pay for this auto-
matic processing of information is that perceptions, mem-
ories, thoughts, and actions have a tendency to err in the
direction of the familiar and the expected.
THE IMPORTANCE OF
ERROR RESPONSE
So, I Made a Mistake . . .
Although it does seem that to err is human and much
of our abilities to make errors is a constant experience
throughout existence, our responses to mistakes are quite
individual. First, some of us simply deny that the error
even occurred by constantly deecting the situation and
taking no ownership of the error itself. Second, others may
be overcome with fear after making an error such that
subsequent similar operations are performed with the sole
focus on not making a mistake instead of performing the
operation correctly. This is a disaster in the setting of
oncologic surgery, in which inadequate resections are per-
formed overshadowed by the constant fear of trying to
avoid ureteral or vascular injuries. Third, some of us are
overcome with passive acceptance. This is the surgeon
who believes that mistakes will always occur no matter
what we do, and therefore, there is no necessity for change
or intervention. Finally, there are those who are deeply
analytical. After we make a mistake, we are self-critical,
analyze the literature, review videos, and channel all of our
energy into self-improvement to minimize the chances of
that error occurring again.
It turns out that our response to making an error is one
of the most important reactions we make in our career.
In residency, we may remember those residents who did
not succeed. What was it about them that made them fail?
Bosk at the University of Pennsylvania studied this and
discovered that failure is related to these responses to
making mistakes. Bosk studied the University of Pennsyl-
vania neurosurgery program and found that the failures
were residents with passive acceptance, who believe that
mistakes will rarely occur or that bad outcomes [have
occurred] due to things outside my control.8 Conversely,
the successful neurosurgery resident was the analytical
surgeon who admits that she or he makes terrible mis-
takes, plenty of mistakes, and is driven to eliminate
failure.
The Residents Response to Error
Paralleling Bosks study, Wu and colleagues9 asked 114
internal medicine residents: How did they handle the
most signicant mistake they made while training? Ninety-
nine percent of the mistakes were serious; in fact, 31% of
these resulted in death. The mistakes included diagnostic
errors (33%), prescribing errors (29%), evaluation errors
(21%), and procedural errors (11%). Amazingly enough,
only 54% of the residents discussed the mistake with the
attending! This remarkably low percentage could be
related to a lack of comfort and/or a power imbalance
between resident and attending to discuss errors. We
argue that there is not an adequate medical culture estab-
lished to allow a healthy, free-owing discussion about
errors. Interestingly, 88% of the residents discussed the
mistake with another physician who was not a supervisor.
And only 24% of the residents reported the mistake to the
patient or the familiesagain, the lack of comfort and
uneasiness with the young trainee in the position of
making an error.
Although this chapter does elucidate the true lack of
error reporting in residency, it also proves that construc-
tive changes can occur after residents accept responsibility
for the mistake and discuss it with the attending physi-
ciannot, however, in forums such as M&M. Indeed,
50% of the residents stated that the real issues were never
discussed at M&M! As stated by Greenberg and associ-
ates,10 According to both attending and resident sur-
geons, the most important personality trait for success in
a surgical residency is the ability to admit error. As Hil-
ker11 stated, We see the horror of our own mistakes, yet
we are given no permission to deal with their enormous
emotional impact. The medical profession simply has no
place for its mistakes.
Is Morbidity and Mortality Conference Enough?
It seems obvious that if the most important component
of a successful surgeon is, rst, the ability to admit error
and, second, to deeply ponder the issues surrounding the
error, then the M&M conference should be one of the
most critical aspects of residency training. Unfortunately,
this may not be so.
 1 FROM ERROR TO PERFECTION: THE PROCESS OF SURGICAL MATURATION
When looking at error response at M&M conferences,
a prospective review of 332 M&M conferences in internal
medicine (n = 232) and surgery (n = 100) was conducted
at an academic medical center.12 Piernissi and coworkers12
showed that M&M conferences may have considerable
room for improvement. Only 38% of the errors in medi-
cine and 79% of the errors in surgery were attributed to
a particular cause, even though cases were discussed longer
in medicine (34.1 min) than in surgery (11.7 min). In
addition, fewer internal medicine cases (37%) versus surgi-
cal cases (72%) included adverse events. In both medicine
and surgery, when errors were discussed specically as
errors, only 40% were discussed explicitly. So what exactly
is happening at these conferences? As surgical educators,
we are aware of the Accreditation Council for Graduate
Medical Education (ACGME) requirements that All
deaths and complications that occur on a weekly basis
should be discussed. Interestingly, not all specialties
mandate a weekly complications conference.
HOW DO WE ACHIEVE PERFECTION?
THE GIFTED AND TALENTED
The Gifted Response to Error
Clearly, the success of any surgeon is related to how he
or she will respond to errors that will inevitably occur.
Going beyond surgery, many believe success in life is
linked to our responses to error. Gladwell8 was interested
in studying those special people that ultimately achieve
colossal success in life (Fig. 13). His article, entitled The
Physical Genius,8 discussed characteristics that link Wayne
Gretzky, the brilliant hockey player, YoYo Ma, the gifted
Figure 13 Malcolm Gladwell. (Courtesy of www.gladwell.com,
Brooke Williams photographer.)
5
cellist, and Charlie Wilson, a brilliant neurosurgeon at the
University of California at San Francisco (UCSF). Gladwell
discovered that one of the most important traits these
people all shared was their drive for awless, error-free
performances.
Gladwell described the inherent traits of Don Quest,
a neurosurgeon at Columbia Presbyterian Hospital in
New York, and what makes him so successful. Yes, Quest
believes that ne motor skills and swift decision making
are important, but are of little value without the right sort
of personality. After studying the successful and failing
neurosurgery residents, Bosk8 described the Quest per-
sonality as those with a practical-minded obsession with
the possibility and consequences of failure. Physical
geniuses are driven to greatness because they have found
something so compelling that they cannot put it aside.8
The Power of Visualization and Chunking
Not only do these gifted individuals deliberate on the
mishaps, but they all have a keen sense of visualization and
are able to live in what is almost an extra dimension of
reality as well. Gretzky has the capacity to pick up on
subtle patterns in the hockey game that others generally
miss; he commonly says that he sees the entire rink, not
where the puck is, but in factwhere the puck will be.
Brilliant surgeons can simultaneously look at tissue planes
and look beyond the recognized anatomy to what lies
behind the operative eld. As Charlie Wilson described in
Gladwells article,8 an ability to calculate the diversions
and to factor in the interruptions when faced with an
internally confusing mass of blood and tissue is the true
description of the gifted and talented surgeon.
The ability to visualize has been described in detail by
Stephen Kosslyn, who discussed four separate human
capacities working in combination.8 The rst ability is to
generate an image, that is, take something out of long-
term memory and reconstruct it. Second, visualization
requires image inspection. Take the mental image and
draw inferences from it. This clearly requires moving from
that image with visualization and making it real and appli-
cable to wherever you are currently working, whether on
an operating eld, a basketball court, or a hockey rink.
Third is image maintenance, the ability to hold the
picture steady so that you can actually make real time and
actually utilize that visualization for practical purposes
doing what you are currently doing right now. Lastly is
image transformation, the ability to take the image and
manipulate it. This means to look at it from multiple
views, rotate it 45, 90, or 180, so that these views will
allow you better capacity to utilize it again during your
immediate need.
Many gifted athletes have discovered that these pro-
cesses can be learned and practiced during mental training
exercises. In addition, the process of visualization in
the gifted mind occurs through patternized thought. The
concept that enables the mastermind to achieve success
 6 SECTION I: GENERAL CONSIDERATIONS
is called chunking. Chunking describes how our mind
stores familiar sequences. Bobby Fischer, the brilliant
grand master chess player talked about seeing patterns,
not individual pieces on the board. Michael Jordan prac-
ticed visualization regularly. He would see the basketball
court and see multiple patterns of defenses that could be
thrown up against him in any given game. He chunked
these typical patterns together and would be able to
respond to these typical patterns quickly. Master surgeons
also chunk together the sequences in operations that they
have performed so many timesthey can see where they
will be in the operation in 10-, 20-, and 30-minute inter-
vals. Chunking patterns together enables these brilliant
individuals to respond quickly to error . . . and prevent the
mistake before it happens because they have been in this
situation so many times before.
THE FUTURE . . . A MEDICAL
CULTURAL UPHEAVAL
Should We Teach the Reproducible and
Predictable Errors We Make?
Training must include . . . a consideration of safety issues.
These issues include understanding . . . how errors can
occur at various stages . . . and instruction in methods for
avoidance of errors.4
Our interest in error training arose from an article on a
step-by-step approach to the laparoscopic Nissen fundo-
plication.13 With each dened step, we identied specic more frequent rest (p. 13). Moreover, if there are com-
pitfalls that could potentially occur at each step. After this
article was published, our residents clamored for similar
articles or modules for every operative procedure in general
surgery, and we began to ask the question, should this
be the way we teach surgery: how to, but also how
NOT to?
THEORIES OF HOW WE ACQUIRE
TECHNICAL SKILLS
The Fitts and Posner Model
In order to understand the processes and bases of teaching
technical skills, we must comprehend, on a theoretical
level, how we acquire skills. The concept of skill acquisi-
tion is surprisingly constant throughout human experi-
ence. Although Reason6 and Rasmussen and Jensen5 set
the foundation for understanding these processes, the elo-
quent and notable treatise, Human Performance, by Fitts
and Posner14 outlined the three fundamental phases for
acquiring performance-based skills (Fig. 14). The rst
is the cognitive phase. During this cerebral phase, we
actively intellectualize the skill or procedure. For example,
we may outline the specic, detailed steps of an individual
procedure and analyze the reasons and rationale for it.
THE FITTS AND POSNER MODEL*
Cognitive phase
Autonomous phase Associative phase
*Human performance, 1969.
Figure 14 Fitts and Posner model. (From Fitts P, Posner MI.
Human Performance. Belmont, CA: Brooks/Cole Publishing, 1969.)
The second, more active, phase of skill acquisition is
the intermediate or associative phase. During this phase,
our old habits which have been learned as individual
units during the early phase of skill learning are tried out
and new patterns begin to emerge.14 We link our thought
process with action: in our case, utilizing eye-hand
coordination. This phase can last for a very short or a very
long time, depending on the complexity of the procedure.
The associative phase is interesting because here we
develop subroutines that make up parts of the whole
skill. We integrate and compile these subroutines in order
to learn the entirety of the skill. In addition, repetition of
each subroutine and each skill is important during this
phase. Fitts and Posner14 actually studied modes of repeti-
tion and showed that too-frequent repetition within a
short period of time will result in a greater depression in
performance than the same amount of repetition with
ponents of the skill that are completely independent of
each other (e.g., typing different passages with separate
hands), it is actually better to practice each component
separately (p. 14).
The third and nal phase of skill acquisition is the
autonomous phase. The autonomous phase occurs when
we feel we have intrinsically learned a task or procedure.
The individual processes and subroutines become autono-
mous, less subject to any cognitive control or any outside
interference or environmental distraction. The individual
practitioner has become unconsciously competent in per-
forming the task.
To reach the autonomous phase requires extensive
practice such that the motor skills reach the unconscious
mode or become automatic. Much has been written about
what are optimal practice patterns, but probably no
one has written more than Ericsson15 at Florida State
University. Ericssons writing on deliberate practice is
broad based and covers a variety of elds including sports,
music and the arts, and also medicine and surgery.
He dened three components of deliberate practice:
(1) focus on a dened task to improve a particular aspect
of performance (which is measurable), (2) repeated prac-
tice, and (3) immediate coaching and feedback in perfor-
mance.15 Whereas most young trainees hope to achieve
 1 FROM ERROR TO PERFECTION: THE PROCESS OF SURGICAL MATURATION
the autonomous phase in their growth and development
such that they are able to perform what is perceived as a
high performance level, there is an interesting twist to
automaticity in any dened skill.
By Ericssons perspective, automaticity actually leads to
an arrested phase of growth in ones personal develop-
ment of her or his own skills. As an example in the prac-
tice of surgery, residents and young surgeons after
multiple repetitive operations in the same area nally
achieve a phase at which they are comfortable with the
operation and are able to, for the most part, perform in
an unconsciously competent fashion, meeting the deni-
tion of automaticity (or the autonomous phase in the Fitts
and Posner model14). This level of competency is the point
at which they have reduced most of their obvious gross
errors such that they are perceived by their peers as being
an excellent practitioner and may in fact, in their own
mind, now have reached expert status. Again, as Ericsson15
dened it, the failure to attain expert status comes because
of complacency with competency. As Ericsson views it,
for aspiring expert performers . . . they must avoid the
arrested development associated with automaticity and to
acquire cognitive skills to support their continued learning
and environment.15 Or, to restate it more bluntly,
Although everyone in a given domain tends to improve
with experience initially, some develop faster than others
and continue to improve during ensuing years. These
individuals are eventually recognized as experts and
masters.
In contrast, most professionals reach a stable average
level of performance within a relatively short timeframe
and maintain this mediocre status for the rest of their
careers. This quote from Ericsson is not to suggest that
the majority of surgeons practicing are mediocre in
their practice, but it does emphasize and elucidate the
point that reaching a level of competency may work
against achieving expert status because of the complacent
nature that the individual practitioner views his or her
capacity to perform.
Error Training and Cognitive Remodeling in
the Fitts and Posner Model
Somewhere along the learning curve of any given skill,
errors are made and learned. By understanding how we
acquire skills and where we learn errors, we can hope not
only to unlearn the errors but also to prevent them from
being learned. Fitts and Posner14 made a brief reference
to the concept of errors when they mentioned where
mistakes can occur during skill acquisition, but certainly
no attention was given to the process of preventing mis-
takes during skill acquisition.
Thus, we propose an extension to the Fitts and Posner
model14 with an interval phase of error training, which
enters the three-phase model after the cognitive phase
(Fig. 15). Introducing error training during skills acqui-
sition allows us to emphasize the errors we inherently
7
THE FITTS AND POSNER MODEL*
Cognitive phase
Cognitive Error training
remodeling phase
phase
Autonomous phase Associative phase
*Human performance, 1969.
Figure 15 Fitts and Posner model of error training and cognitive
remodeling. (From Fitts P, Posner MI. Human Performance. Belmont,
CA: Brooks/Cole Publishing, 1969.)
make while gaining skills. These errors are commonly
predictable and, unfortunately, durable. Conversely, while
we learn a given skill set, we can preemptively recognize
the common errors that will occur for the given skill set
so as to NOT learn them.
It is crucial that error training occurs prior to the inter-
mediate or associative phase when actions become more
innate and intuitive. We may all know that the worst error
made is one that is not recognized. In addition, we propose
that there is a cyclical way that we learn and perform skills
so that cognitive remodeling occurs as we become more
knowledgeable and more experienced in the procedure.
After a prolonged period of time performing the same
procedure, we begin to rethink the procedure and how
we carry out the task. We recognize where we can move
quickly and where we must move slowly in an operation,
we eliminate wasteful movements, and so on. This cogni-
tive remodeling is a desired process as surgeons mature in
their approach to a specic procedure.
It is this dimension of error training that we hope to
emphasize in this book. It should be central to how we
learn skills and, moreover, is crucial to understand as we
train residents and young surgeons in our craft. By recog-
nizing pitfalls while we train, and focusing on the ways to
eliminate them, we start to look at the procedure differ-
ently, from a more careful perspective. We think about
how we do the operation, how to rene it and to establish
more efcient and effective steps in the ultimate polished
and perfect result. It may not be too far-fetched to argue
that a focus on error training may prove to be an extremely
useful part not only of the medical educational processes
of performance-based skills, but also of the global patient
safety initiatives that we hope may change the way we
practice medicine.
To help answer this question, Rogers and colleagues16
at Southern Illinois University published an elegant but
quite simple study to show the impact of error training.
Thirty senior medical students were assigned to one of
four different training groups to learn two-handed knot
tying. The groups included (1) no training, (2) error
training only, (3) correct training only, and then (4) error
training plus correct training. They then compared all four
 8 SECTION I: GENERAL CONSIDERATIONS
groups. Overall, 11 errors were identied; the 4 most
common accounted for 75% of the total errors. Too much
right-handed motion accounted for 38% of the errors;
failure to maintain consistent tension, 17%; hands too
close to the knot, 17%; and failure to cross the hands, 7%.
Rogers and colleagues16 showed that common and even
predictable error training coupled with correct skills train-
ing clearly leads to superior skills acquisition. One could
extrapolate from this that, in fact, predictable errors can
be identied and delineated from virtually any operation
and utilized in global skills training.
In Way and coworkers article7 outlining common bile
duct injuries in laparoscopic cholecystectomies, the errors
were not only predictable but in fact also reproducible.
Would it improve national outcomes if the resident and
practicing surgeon learning the basics of the laparoscopic
cholecystectomy also learned the steps that lead to preven-
tion of these described errors?
Let us look at this a little differently. Can the ability to
detect errors during an operation when observing someone
or observing videos have any correlation to skill level?
Bann and associates17 took 38 volunteer surgeons and
recruited them to undertake three exercises. Two of these
were bench-top tasks that were scored using Objective
Structural Assessment of Technical Skills (OSATS) global
rating techniques. The third was the ability to detect
simple errors in 22 synthetic models of common surgical
procedures. Those volunteers who were able to detect
errors clearly performed with a higher technical ability
than those who could not (P < .5). Does this simply mean
that those individuals who can detect errors as an external
observer are more sophisticated in their ability to carry out
the procedure? This study would certainly make that argu-
ment, and in fact, understanding errors in skills acquisition
is probably an additional level above and beyond what
individuals are currently trained to do.
Information Overload
The downside of error training is information overload.
Just learning how to do a procedure, on both a cognitive
and a technical level, can be overwhelming for trainees
and young surgeons. The vast majority of textbooks and
analysis in surgery are geared toward how to do the oper-
ation, not how NOT to do the operation.
We may think that we all respond differently to informa-
tion overload, but Miller18 in the 1960s studied the human
response to this excessive input and discovered three broad
responses. First, we may work faster and faster, trying to
somewhat battle the input, and continue to let errors
occur, just hoping to nish the learned task. The second
response is to disregard or lter out part of the informa-
tion that we are trying to learn so as to learn only a part
of the whole. The third response to information overload
is called queuing, in which our brain places the input mes-
sages on hold and asks them to wait in line. The informa-
tion becomes backed up and then one by one lters back
in slowly but methodically.
Unfortunately, in the process of learning a complex
operation and simultaneously learning how not to do the
operation could lead to a complete disregard or foraging
out of part of the information. But we do not think this
warning should inhibit us from focusing on teaching tech-
nical errors.
E. F. Schumacher, a Nobel laureate who wrote Small
Is Beautiful and also A Guide for the Perplexed, is quoted
in the latter book on how we should approach an issue
that is as complex as the issues centered around patient
safety, medical mistakes, and resident error training: Can
we rely on it that a turning around will be accomplished
by enough people quickly enough to save the modern
world? This question is often asked, but whatever answer
is given to it will mislead. The answer yes would lead
to complacency, the answer no to despair. It is desirable
to leave these perplexities behind us and get down to
work.
Error Training
The most fruitful lesson is the conquest of ones own error.
Whoever refuses to admit error may be a great scholar but
he is not a great learner. Whoever is ashamed of error will
struggle against recognizing and admitting it, which
means that he struggles against his greatest inward
gain.Johann Wolfgang von Goethe (17491832),
Maxims and Reections
As we began studying human performance, technical skills
acquisition, the gifted and the talented, resident training,
and medical mistakes, we realized that we may need
a novel approach to how we think about surgery. More
importantly for the future, a novel approach to how we
teach our craft. We cannot expect that we will all study
the Fitts and Posner model14 with error training and cog-
nitive remodeling and hope that this will be a basis to
enhance skills performance and to, ultimately, minimize
technical errors.
Little has been published on surgical errors and error
prevention. Anatomic Complications of General Surgery,
Skandalakis and coworkers19 beautiful book published in
1983 (currently no longer in press), is a staple and main-
stay for many surgeons libraries. Greeneld published his
book, Complications in Surgery and Trauma, in 1984.20
It was updated by Mulholland and Doherty as Complica-
tions in Surgery in 2006.21 However, the focus has not
been on purely cognitive or technical errors. However,
something still seems to be missing because we continue
to see the same mistakes over and over again.
It is quite clear that errors will always occur from the
level of the intern all the way to that of the gifted surgeon.
The mechanisms of errors are slowly being understood,
both from a theoretical perspective and also from an
extremely practical perspective. The common mistakes
that are made technically and cognitively for each disease
and for each operation are now becoming more clearly
 1 FROM ERROR TO PERFECTION: THE PROCESS OF SURGICAL MATURATION
understood, and these common repetitive errors are
predictable and allow an excellent opportunity for error
training that is individualized for each procedure and each
diagnosis. In addition, responses to error are poorly devel-
oped, poorly role-modeled, and poorly implemented
making it difcult for surgical trainees, young surgeons,
and experienced surgeons alike. The concept of error
training may clearly play an important and signicant role
in error reduction. This textbook attempts to dene spe-
cic technical and cognitive errors for a large breadth and
depth of operations in surgery with the hope and intent
of establishing a comprehensive encyclopedia of pitfalls
that can occur in surgery that can be utilized by both
young and old surgeons for years to come.
Nothing stands out so conspicuously, or remains so rmly
xed in our memory, as something in which we have
blundered.Cicero, De Oratore, I, 129
REFERENCES
1. Institute of Medicine. To Err Is Human. Washington,
DC: National Academies Press, 2000.
2. Leape L, Berwick D. Five years after To Err Is Human
what have we learned? JAMA 2005;293:23842390.
3. Brennan TA. The Institute of Medicine report on medical
errorscould it do harm? N Engl J Med 2000;342:1123
1125.
4. Leape L. Error in Medicine. JAMA 1994;272:18511857.
5. Rasmussen J, Jensen A. Mental procedures in real-life
tasks: a case-study of electronic trouble shooting.
Ergonomics 1974;17:293307.
6. Reason J. Human Error. Cambridge, MA: Cambridge
University Press, 1992.
7. Way LW, Stewart L, Gantert W, et al. Causes and
prevention of laparoscopic bile duct injuries. Ann Surg
2003;237:460469.
9
8. Gladwell M. The physical genius. The New Yorker,
August 2, 1999; pp 5765.
9. Wu AW, Folkman S, McPhee SJ, Lo B. Do house ofcers
learn from their mistakes? JAMA 1991;265:20892094.
10. Greenburg A, McClure D, Penn N. Personality traits of
surgical house ofcers. Surgery 1982;98:368372.
11. Hilker D. Facing our mistakes. N Engl J Med 1984;310:
118122.
12. Piernissi E, Fischer MA, Campbell AR, Landefeld CS.
Discussion of medical errors in morbidity and mortality
conferences. JAMA 2003;209:28382842.
13. Evans SRT, Jackson P, Czerniach D, et al. A stepwise
approach to laparoscopic Nissen fundoplication: avoiding
technical pitfalls. Arch Surg 2000;135:723728.
14. Fitts P, Posner MI. Human Performance. Belmont, CA:
Brooks/Cole Publishing, 1969.
15. Ericcson KA. Deliberate practice and the acquisition and
maintenance of expert performance in medicine and
related domains. Acad Med 2004;79(suppl 10):570
581.
16. Rogers DA, Regehr G, MacDonald J. A role for error
training in surgical technical skill instruction and evalua-
tion. Am J Surg 2002;183:242245.
17. Bann S, Khan M, Datta V, Darzi A. Surgical skill is
predicted by the ability to detect errors. Am J Surg
2005;189:412415.
18. Miller JG. Adjusting to overloads of information. In.
Rioch DM, Weinstein EA (eds): Disorders of Communi-
cation. Research Publications, Vol 42. New York: Associa-
tion for Research in Nervous and Mental Diseases, 1964;
pp 87100.
19. Skandalakis JE, Gray SW, Rowe JS. Anatomic Complica-
tions in General Surgery. New York: McGraw-Hill,
1983.
20. Greeneld LJ. Complications in Surgery and Trauma.
Philadelphia: JB Lippincott, 1984.
21. Mulholland M, Doherty G. Complications in Surgery.
Philadelphia: Lippincott Williams & Wilkins, 2006.
2
Teaching Technical SkillsErrors in
the Process
Hugh M. Foy, MD and Stephen R. T. Evans, MD
INTRODUCTION
The primary duty of a surgical educator is to help instill
the knowledge, skill, and attitudes that will help develop
the trainee into the very best surgeon possible. Experience
tells us that the success of an operation depends on innu-
merable factors, some controllable, others not. A success-
ful operative procedure is the cumulative sum of thousands
of perfectly done steps. It follows logically that our primary
responsibility as surgeons is to ensure that our technical
input is as perfect as possible, given that much else is
subject to chaos, chance, and the attention of others.
When teaching surgical technique, it becomes even more
important to ensure the quality of our craft by our precise
and professional instruction of our residents, while at the
same time allowing the necessary graduated responsibil-
ity that is important for the professional development
and maturation of a surgeon.1a
Our technical input is, in fact, the only factor that is
in our direct control. The other external factorsthe
patients premorbid state, anesthetic care, alteration
in normal physiology and unanticipated physiologic
deteriorationare far less controllable. All of these con-
ditions continually threaten the surgeons best inten-
tions and technical skill. A surgeons technique must,
therefore, be as perfect as possible in order to tip this
precarious balance in the favor of the restoration of
the patients health. As Bosk remarked in his well-
known sociologic study of surgery training, Forgive and
Remember, Every time a surgeon operates, he is making
book on himself. Besides the enormous amount of theo-
retic and technical expertise that is his cognitive capital,
the surgeon carries in his head an odds-book for each
procedure.1
Much attention had been focused on how the principles
of aviation safety and training might apply to the practice
of medicine in general and, specically, the training of
surgeons.2 Training strategy in both aviation and surgery
share some important similarities: (1) They require a body
of prerequisite knowledge; (2) They are highly technical;
(3) They are done in the setting of unforgiving circum-
stances; (4) They require quick, precise decision making;
and (5) They require a sequence of subroutines and grad-
uated responsibility. The fundamental inescapable fact in
both activities is that human life is held in a precarious
position: Our patients life is suspended by general anes-
thesia as the plane and its pilot are suspended in the air
by aeronautical engineering. Both medicine and aeronau-
tical engineering are constantly defying unforgivable laws
of nature. Ignore either of these basic supports during the
endeavor and death is imminent. Both activities are pressed
by time, are charged with intensity, and occur in a variable
physical environment in which errors can quickly result in
morbidity and mortality. Both require training, skill, prac-
tice, and quick decisions that are often made with limited
data.
However, important differences between training sur-
geons and training pilots limit the application of the avia-
tion model to surgery. Recently, a consulting rm has even
proposed to help apply the principles of the highly techni-
cal training of ghter pilots to surgical programs and to
our professional organizations that seek to improve the
training of surgeons. The differences are notably in the
setting, engineering parameters, and the resultant simula-
tion equipment. Pilot training in the last several decades
has occurred in a very controlled setting. Candidates are
selected after extensive examination with batteries of tests
grading their intellectual, physical, psychomotor, and
emotional abilities. Before any actual ight training begins,
they attend months of didactic lectures in ground school,
learning the principles of aeronautic engineering, meteo-
rology, and nally, the engineering specics of generic and
individual aircraft.
The previously described process sounds fairly similar
to our medical schools curriculum in the basic sciences
and clinical clerkships in the various medical specialties.
Aviation, however, is much more focused and, by its very
nature, precisely dened, described, and quantied by the
principles of aeronautical engineering. As a consequence,
simulation techniques have been somewhat easier to
develop. Equally signicant, the threat of war and a sub-
stantial military budget helped catapult the eld of ight
simulation in its inception during the days leading up to
World War II.
 12 SECTION I: GENERAL CONSIDERATIONS
Actual ight training begins in a simulator, safe from
the unforgiving reality of gravity. When the student proves
procient, she or he takes to the air in a real plane with
an instructor. Obviously, pilots must learn to y in less
threatening, noncombat conditions before they learn
the more complicated and dangerous skills of air-to-air
combat. Further screening and selection nally distills the
pool of aviators to the select group of highly skilled ghter
pilots. Here, too, however, training is done in the absence
of live re from a real enemy. Ironically, military avia-
tion has not been faced with a real-life, direct lethal threat
from a capable enemy force for more than 50 years, other
than occasional re from surface-to-air defensive missiles.
The enemy is usually a colleague who chases the trainee
through the air or a computerized threat in a highly devel-
oped virtual environment. Following the live ight exer-
cise, the scenario is reviewed and dissected in a lengthy
debrieng often lasting many hours.
In stark contrast, surgery training has traditionally been
conducted under the live re of a real patient who may
suffer dire consequences from our mistakes. In decades
past, the instructor was often a senior resident, with barely
more experience than the learner. In addition, a very large
portion of surgical education occurs in our large, mostly
public-sector, safety-net hospitals and trauma centers in
which logistic challenges heighten the high stakes of a
real-live patient. Ironically, all too often, the number of
patients and the serious degree of their illness are inversely
proportional to the logistic support and supervision
provided to the trainee. Our trauma centers often serve as
our major training centers in which precious little time is
available to methodically train residents in the aviation
paradigm. Fortunately (and ironically), supervision by
attendings has improved as a result of considerable pres-
sure and actual laws enacted and strictly enforced by the
federal government that require the attending to be phys-
ically present in the operating room in order to be paid.
Unfortunately, a frequent occurrence in this resource-
constrained environment is for the attending to nd
himself or herself trying to juggle several overlapping cases
with trainees who have little prior experience.
It is exactly these constrained resources and variable
experience of trainees that may make aviation-based
models all the more important and potentially helpful
adjuncts to our classic training model of see one; do one;
teach one. The knowledge of such approaches can help
make the surgical instructor more efcient and the resi-
dent better educated. Often, the teaching moment is
effectively the only opportunity for the teacher to cover
the various tenets of surgical and technical training, from
the assessment of the residents prior experience to the
review after the case of what might we have done differ-
ently. Surgical educators, lacking the luxury of hours to
accomplish activities like their counterparts in aviation
training, must recognize and make effective use of these
eeting teaching moments to ensure the safe conduct
of the patients surgical care.
Our primary objective as surgical educators should be
to present to the trainee the most basic, conservative, reli-
able, and safe techniques. Short cuts that require advanced
clinical judgment can be saved for later as the resident
matures. First and foremost, the trainer must emphasize
attention to detail, adherence to Hallsteads principles of
surgery, and consideration of the emotional needs of the
patient and staff. It all boils down to what they know,
what they can do with their hands, and what they do with
their heartsotherwise known as the cognitive, psycho-
motor, and affective domains of learning.
BASIC PRINCIPLES OF SURGICAL
TECHNICAL INSTRUCTION
AND LEARNING
Until recently, little has been written regarding the theory
and tenets of teaching and learning in the operating room
(OR). The advent of minimally invasive or videoendo-
scopic surgery heralded by the development of laparo-
scopic cholecystectomy in the late 1980s and its
unforgiving two-dimensional perspective stimulated a
renaissance in surgical technical training. From the days
of Halstead, certain fundamentals have been espoused
but rarely written. Recently, hundreds of articles have
been published as attention to skills training has virtu-
ally exploded. Consistent with Halsteads reclusive
nature, his principles remain more the oral, rather than
the written, tradition of surgery. During the development
of the rst formal training program for surgeons in this
country, Halstead would admonish his trainees to care-
fully consider the root cause of any technical complication.
These principles are best remembered in the order in
which they are applied during the normal course of an
operation:
1. Aseptic technique.
2. Adequate exposure.
3. Cutting under tension and countertension.
4. Adequate hemostasis.
5. Gentle handling of tissues.
6. Dbridement of devitalized tissue.
7. Obliteration of dead space.
8. Assurance of adequate blood supply.
9. Avoidance of excess tension on the suture line.
The specic conditions and psychomotor training prin-
ciples have been outlined in various resources and can be
helpful in discussing complications that may result from
a lack of appreciation and application by the surgical
instructor. Learning any motor skill is distinctly different
from learning verbal or intellectual skills. Motor skill
learning requires application of a chain of responses, or
ordered, linked tasks, that cannot be accomplished until
the preceding task is nished. Like the sign above the
confused cartoon characters bed: pants rst, then shoes.
The precise incision cannot be made until the right amount
 2 TEACHING TECHNICAL SKILLSERRORS IN THE PROCESS
of tension and countertension is applied to the skin. The
suture cannot be tied until it is precisely placed in the
bowel wall. The artery should not be incised before prox-
imal and distal control are obtained. This succession
of tasks has also been described as the organization of
subroutines.3
Certain conditions make learning a technical skill more
likely. Contiguity, or the repeated attempts in close
chronological sequence under similar but slightly different
conditions, will greatly enhance learning. One cannot
learn to ride a bike by trying once today and repeatedly
at monthly intervals. Repeated attempts allows for repeated
corrective actions. Corrections in ones technique on
repeated trials will oscillate about the mean, which is the
desired behavior. Learning a very complex skill like slalom
water-skiing is extremely difcult and can be accomplished
only by repeated corrections in which the novice rst leans
too far forward, then too far back, incrementally making
smaller adjustments, and nally, on the 10th or 12th
attempt stands up, propelled by perfect tension on the
rope that transfers the force and speed of the boat. Neither
learning to ride a bike nor learning slalom skiing can be
achieved while standing still. Both require movement,
momentum, and real-time feedback by an instructor. The
same is true of operative skill.
Analysis of common bile duct injuries in the early years
of laparoscopic cholecystectomy revealed that most inju-
ries occurred in the rst 12 to 20 attempts at the proce-
dure, implying that a plateau of initial competence was
more likely after a dozen or so attempts.4
The intern will never learn more about inguinal herni-
orrhaphy than when she or he performs three such cases
in a single morning. Here, they can nally appreciate the
subtle differences in the variable muscular and aponeu-
rotic contributions of the internal oblique muscle, the
variance in the size and shape of the hernia sac, and other
inherent differences in anatomy and pathology, while the
basic steps and repair technique remain constant.
THE OPERATIVE PROCEDURE:
SETTING, LOCATION, AND PITFALLS
Much attention has been given to the technical or the
psychomotor aspect of performing an operation: the actual
cutting and sewing of tissues during the procedure. All
domains of learning are important contributions to the
learning of the trainees and the successful outcome of
their patients. Learning theorists maintain that there are
three classic domains of learning: cognitive, psychomotor,
and affective. Chronologically, the operative learning
experience can be said to have three periods: preoperative,
intraoperative, and postoperative. In each period, all three
domains of learning are important, but one may often
predominate. In the preoperative phase, the cognitive
domain is predominant. A careful interview of the patient,
applying the skills rst introduced in medical school, is
13
vital to extracting important information regarding the
unfolding of the symptom complex in a pattern from
which a provisional, clinical diagnosis is made. Inattention
to detail, either in the patients history or in the review of
his or her previous records and diagnostic studies, can
have signicant deleterious effects on intraoperative deci-
sion making and postoperative management. Lack of
psychomotor skill in performing a physical examination
can also be problematic.
Obtaining an informed consent from the patient is one
of the most demanding of all affective tasks facing the
surgeon. Informed consent is much more than merely
having the patient or their representative sign a form.
Unfortunately, all too often this task is delegated to a
more junior team member, sometimes one not even
involved in the actual operation. A properly done informed
consent involves several steps:
Step 1 Education of the patient.
Step 2 Description of the differential diagnosis and
relative degree of certainty of the working diag-
nosis based on available information and tests.
Step 3 Explanation of the indications and steps of the
proposed procedure.
Step 4 Mention of alternative forms of treatment, their
relative success rates and why the proposed pro-
cedure is, in the judgment of the surgeon, the
preferred alternative.
Step 5 A description of the possible complications, both
generic (such as bleeding, infection, and the risk
of anesthesia) and also ones more specic to the
particular operation.
Step 6 The expected postoperative course and eventual
outcome.
PREOPERATIVE PITFALLS
COGNITIVE PHASE OF SKILLS
ACQUISITION
Most of the work of the preoperative phase involves the
cognitive realm of learning and the cognitive phase of
skills acquisition. The indications of the operation should
be clear, and the intellectual preparation should be accom-
plished through studying the appropriate educational
materials and thoroughly reviewing the patients history,
examination, and diagnostic studies. However, more
subtle tasks need to be attended to: (1) performing a
learning needs assessment (LNA), (2) dening goals
and objectives, and (3) familiarizing oneself with the nec-
essary equipment to be used.
Learning Needs Assessment
LNA is the process of determining the previous experience
of a learner so that the teacher can better tailor the instruc-
tional focus to the individual resident or student. Failure
to accurately inquire and appreciate the prior experience
 14 SECTION I: GENERAL CONSIDERATIONS
and knowledge can result in inefcient and unnecessary
frustration for both the attending and the resident and
affect patient outcome. Underappreciation of a learners
capabilities may result in hovering unnecessarily, teaching
skills she or he has already mastered, and wasting the time
of all involved. This is more likely to be the case early in
the academic year. As the year progresses, it is more likely
to occur at the beginning of a rotation in a larger program
in which the attending may have little or no prior experi-
ence or knowledge of the newly arrived resident on the
service.
Basic Principle
Prior to beginning the procedure, the attendings must
obtain knowledge of the operating residents prior experi-
ence. They must ask the learner. The teaching assistant
must not assume but must ask the resident what his or
her prior experience has been, including (1) factual or
cognitive knowledge of the case, (2) prior operative expe-
rience, and (3) awareness of common pitfalls and compli-
cations. It is critical that the attending establish the level
of instruction necessary to avoid either overestimating or
underestimating the residents ability. Overestimating a
residents abilities can have disastrous consequences. Con-
versely, underestimation of technical ability carries the risk
of insulting the trainee and wasting precious time. In
smaller programs, this is less likely a problem because
attendings and residents often spend more time together
in longer rotations characterized by more intimate contact
in the OR. In larger programs spread across several inte-
grated institutions, this is less likely and a careful LNA is
of critical importance.
In addition, attendings may overestimate residents
abilities based on their own prior experience delving into
their memory of decades long passed. Often, one hears
the admonition, Why a chief resident should be very
capable of doing a routine colectomy with a junior resi-
dent. Such an assumption may be based on the attend-
ings memory of their training program in decades past in
which direct attending supervision was sparse as best,
particularly on emergency cases at night. Surgery has
changed dramatically in the last several decades. Most
notably, attending presence in the OR has signicantly
increased. More recently, the 80-hour work week restric-
tion has compounded the insidiously diminished indepen-
dent responsibility of the resident. We can no longer make
assumptions based on the past. Sound practice is to include
the LNA in the preoperative checklist in order to avoid
potential disastrous complications based on false assump-
tions, as illustrated in the following scenario.
Example: Overestimating a Residents Capability
A patient is brought to the emergency room with a stab
wound in the left third intercostal space in the midcla-
vicular line. The patient is hypotensive with signs of cardiac
tamponade. The chief resident, now halfway through her
or his nal year, is known to be one of the best in the
program, seasoned with 2 extra years in the laboratory and
accepted as a good team leader. The attending assumes
that she or he has the prerequisite knowledge of cardiac
repair and stands by ready to help. After the resident deftly
performs an anterolateral thoracotomy, incises the pericar-
dium, and relieves the tamponade, the patient improves.
A 1-cm, nonbleeding laceration in the right ventricle is
noted and repair is attempted with a running suture using
a monolament suture, which tears the ventricle and
results in massive hemorrhage. Fortunately, the attending
looking over the residents shoulder is nally able to repair
the enlarged wound with a generous supply of pledgets
and appropriately placed horizontal mattress sutures. If
only one could live the last few moments over again and
simply ask the resident, Have you ever sewn a laceration
in a beating heart before?
Grade 4 complication
Alternative Scenario
Before beginning the thoracotomy, the attending turns
to the chief resident and asks if she or he had ever sewn
a traumatic laceration in a beating ventricle, making
sure to distinguish the technique as uniquely different
from closure of the atrium. The resident remarks that
she or he has not, and the attending describes the appro-
priate technique of using horizontal mattress sutures over
pledgets to help distribute the tension and avoid further
injury.
Discussion: Particularly in emergent cases, failure to
accomplish an LNA in a timely, precise manner can have
dire consequences. A precise and specic inquiry must be
made of the learner, because transference from one tech-
nique in one anatomic structure cannot necessarily be
made to another. As the example illustrates, the technique
for closure of the atrium, commonly done in elective
surgery after decannulation, is distinctly different from
closure of a laceration in a beating ventricle.
Example: Underestimation of a Residents Experience
On a busy Monday morning, the OR schedule is full. It
is the beginning of the year, and the rst case is a recurrent
inguinal hernia in an obese patient. The chief resident
hastily assigns residents to cases. Much to the attendings
chagrin, an intern reports to the OR to scrub on the case.
The attending, faced with a busy schedule full of overlap-
ping commitments, is disappointed and visibly agitated,
complaining that a more experienced resident has not
been assigned to this case, which will require skills in
reoperative surgery far beyond the ability of an intern.
Irate and upset, the attending lets his or her disappoint-
ment show, alienating not only the intern but also the
circulating nurse, scrub technician, and anesthesiologist.
The air in the room is icy cold, and tension runs high.
Halfway through the case, a trauma code is called and the
attending becomes further agitated as he or she realizes
that the case cannot be left for the intern alone to proceed,
even with the more mundane aspects.
 2 TEACHING TECHNICAL SKILLSERRORS IN THE PROCESS
Alternative Scenario
The attending takes a deep breath, holds his or her words
of disappointment and gathers the best equanimity he or
she can muster, reminding himself or herself that he or
she is here, at this hospital, to teach and to teach all,
regardless of ability. A exible approach with the attend-
ing doing the more difcult part of the case is outlined as
the case is briey discussed with the resident at the scrub
sink. As the case proceeds, the attending is surprised at
the technical facility of the intern, particularly with dissec-
tion through the scarred tissue. Remarking at the interns
skill, he or she is reminded that the intern is a transfer to
the program, having recently immigrated to the United
States after completing 4 years of training in the home
country. When the trauma code is announced, the attend-
ing pages his or her partner to cover.
Discussion: Performing an LNA is accomplished by
simply asking the resident about prior experience with any
particular procedure. It is best done early, before the
procedure begins. A brief inquiry into the residents prior
knowledge and experience in general and in a particular
case helps better set the stage and adjust the attendings
expectations appropriately. Nothing can be more disap-
pointing than false expectations unmet. Emotional control
and attitude can prevent a chilling, negative atmosphere
in the OR that affects all personnel. Done properly, an
LNA sets the stage with realistic expectations and will
more likely result in an educational activity characterized
by the appropriate and productive levels of anxiety, prep-
aration, and care.
Dened Goals and Objectives
Basic Principle
Before beginning any operation, it is important to pre-
cisely dene the goals and objectives of the operation.
Much attention has been paid to goals and objectives in
clinical education, and most accrediting bodies require
that these be put in writing for all rotations, programs,
and even individual lectures. Simply stated, goals are what
one wishes to accomplish and objectives are the means
by which the goal is to be reached. Goals can be multiple,
and if so, they must be prioritized. Objectives are the
how and what of an operation. They can be both assign-
ing appropriate roles for different members of the team
and determining strategy for the operation. Sometimes,
the goal of the operation is obvious: Remove the
gallbladder is the goal in an elective cholecystectomy. In
an exploratory laparotomy for an unstable trauma patient,
the goals may be multiple and more obscure, particularly
for the neophyte resident. Restatement of the priorities
involved in more complex operations is important; other-
wise, trainees may be distracted by less critical tasks at
hand.
When faced with multiple procedures in a single opera-
tion, it is helpful to lead the resident through the list of
procedures necessary and assign their relative priority,
15
keeping in mind that the most critical procedures must
be done rst in the event the patient becomes unstable
and the operation is aborted or curtailed. In an explor-
atory laparotomy for trauma, the priorities are assigned
along lines akin to the basic principles of resuscitation:
(1) stop the bleeding, (2) control contamination, and
(3) repair and reconstruct damaged structures if not
deemed unwise and unsafe because of the dangerous triad
of hypothermia, coagulopathy, and acidosis. In an other-
wise stable patient in whom many different reconstructive
or reparative procedures are needed, it is important not
to burn any bridges nor to perform irreversible steps
before other, less denitive intermediate steps are accom-
plished. The most important task should be accomplished
rst, such as performing the descending colostomy before
reanastamosing the terminal ileum so as to not leave the
patient with a blind loop obstruction of the ascending
colon with no route of decompression if the case needs
to be terminated early. Similarly in any individual proce-
dure, one should not divide the colon before the mesen-
tery is rst mobilized and taken down and the vessels
ligated.
Assigning the precise roles of the members of the
surgery team before the operation begins is critical so that
each individuals expectations are clear and appropriate
and confusion is subsequently minimized. Typically, only
one person can direct the operation as the teaching rst
assistant, whether it is the attending or the chief resident.
If both the attending and the senior resident are scrubbed
in to help a junior through the case, then the roles should
be dened ahead of time. Often, the attending will act as
second assistant, chiming in with tips to help the case
move along more smoothly.
Example: Unclear Assignment of Operative Roles
An unstable patient is brought expediently to the OR after
an ultrasound revealed a large amount of blood in the
peritoneal cavity. The 3rd-year resident rotating on the
service from another afliated program missed the orienta-
tion session the day before and arrived in the OR eager
to do the laparotomy, get the numbers, and fulll her
or his operative trauma experience required for comple-
tion of residency. She or he was unaware that the trauma
service policy was for all unstable patients cases to be
done by the chief resident until hemorrhage control is
established and the case is deemed appropriate for a less
experienced resident to be the primary surgeon. She or
he steps up to the patients right side and helps drape the
patient, eager to accept the scalpel and begin. The attend-
ing arrives, asks her or him to step back so that the chief
resident can begin. The visiting resident, visibly disap-
pointed and upset, reluctantly agrees. Over the course of
the next several days, she or he is sullen, argumentative,
and uncooperative. She or he complains to her or his
home program director who calls the chief of trauma to
complain.
 16 SECTION I: GENERAL CONSIDERATIONS
Alternative Scenario
Unable to either turn back the clock or completely orient
the visiting 3rd-year resident before the emergent case,
the chief resident informs her or him of the policy for the
chief resident to perform the case with the attending until
the patients stability is ensured. The chief resident apolo-
gizes and refers the 3rd-year resident to the section in the
orientation packet that states the policy and where in the
coordinators ofce a copy can be picked up. The chief
resident asks that the 3rd-year resident assist if the attend-
ing is delayed in arriving to the OR.
Example: Lack of Prioritization of Multiple Operative Tasks
The same trauma patient, when explored, is found to have
ruptured spleen, extensive mesenteric lacerations, and
multiple bowel perforations. All four quadrants are packed
off, which appears to control the hemorrhage from the
left upper quadrant. The bleeding mesentery is examined
and the vessels ligated. The sigmoid colon has deep, full-
thickness injuries through the wall with fecal spillage. The
residents dbride the edges and close the sigmoid injury
in two layers. Suddenly, the anesthesiologist announces
that the patients blood pressure is 50 mm Hg, and the
laboratory panel returns with evidence of worsening
acidosis and coagulopathy. Still, little or no blood seems
to be coming from the left upper quadrant. The patient
develops high inspiratory pressures and nearly arrests. The
packs are removed from the splenic fossa to reveal that the
ruptured spleen has been bleeding into the chest through
a 6-cm-long posteromedial tear in the diaphragm.
Alternative Scenario
The teaching assistant calmly reiterated the principles and
priorities as the abdomen was being opened, helping all
involved to understand the priorities involved. After liga-
tion of the bleeding mesentery, the colon injury is quickly
stapled off, leaving the repair or diversion for later. The
left upper quadrant is reexplored, the spleen mobilized
and removed, the diaphragm repaired, and a left chest
tube placed.
Discussion: Goals and objectives for any learning oppor-
tunity need to be clearly stated to all members of the team
before proceeding. Preferably, this can be accomplished
before the operation: in a preoperative planning confer-
ence or at the scrub sink after LNA has been done. In
emergency cases, it should occur as the team is assembled
and the surgeons are gowning, draping, and making the
incision. It takes only a minute. If neglected or omitted,
it can have catastrophic results. The teaching moment is
often just that long, and the opportunity can be lost just
as quickly.
Equipment Familiarization
Basic Principle
For many generations, most surgical procedures were
fairly constant in their design, conduction and equipment.
Since the late 1980s there has been an explosion in the
approach, technology, and innovation spurred on by min-
imally invasive surgery. In the early years of laparoscopic
cholecystectomy, many complications occurred owing to
lack of appreciation of the lack of depth perception in this
new two-dimensional environment, unfamiliarity with
newly developed equipment, and hidden liabilities of
certain, seemingly innocuous aspects like CO2 insufation.
Technical adaptations of the procedure, anticipation of
potential complications, and improvements in instrumen-
tation have overcome many of these challenges. Regard-
less of these advances, it remains critical for the surgeon
to be familiar with whatever equipment may be needed.
As new and better instruments are developed, prior famil-
iarization with equipment is ever more important.
Example: Unfamiliarity with Equipment
A senior resident is assigned to help a new attending with
a laparoscopic colon resection. The attending assumes that
the resident has completed the endoscopic stapled anas-
tomosis exercise in the technical skills laboratory. Unfor-
tunately, she or he is in the half of her or his class that
was to receive the training in the latter half of the year.
The resident rushes to the OR to nd that the case has
been started with the fellow. The resident scrubs in and,
as the case proceeds, is asked to step forward to perform
the anastomosis. She or he is given the endoscopic stapler
as the attending lines up the bowel for a side-to-side
anastomosis. The stapler is threaded into the bowel and
the resident attempts to re it, not realizing that the scrub
techncian has failed to remove the safety tab that blocks
the instruments ring. Not wanting to be seen as incom-
petent, the resident forcefully closes and res the stapler,
breaking the handle. No other stapler is available that is
suitable for the case, and the case requires conversion to
an open procedure to complete the anastomosis.
Alternative Scenario
A new stapler is proposed to be added to the general
surgery inventory. Prior to approval, the manufacturers
representative demonstrated the device at a regular faculty
meeting and the following week to the residents in their
weekly technical skills laboratory. Before using it in the
OR, the attending asked the resident if she or he was
familiar with the instrument and had attended the dem-
onstration session. The resident carefully inserted the
stapler into the lumen of the bowel, realized that the safety
tab was still in place, removed it, and red it as she or he
announced the specic steps in the procedure out loud to
the attending and the rest of the team.
Discussion: In an ever-changing surgical environment
characterized by constant innovation, it is imperative that
new instruments are formally introduced and that all sur-
geons, trainees, and attendings alike be instructed in their
proper use before they are to be utilized in the OR on a
live patient. Dened curricula and technical skills labora-
tories have sprung up in training institutions around the
 2 TEACHING TECHNICAL SKILLSERRORS IN THE PROCESS
country, and formal accreditation protocols have been
established to ensure a safe venue for familiarization and
practice before the trainee is expected to use new instru-
ments and techniques in the OR. Accreditation of resi-
dents in many procedures, both old and new, such as
central line insertion, is advocated to make sure that the
residents have been properly instructed and proctored
through their initial attempts and that their competence
is certied before they are allowed to perform the proce-
dures independently.5
INTRAOPERATIVE PITFALLSTHE
FIXATIVE AND AUTONOMOUS
PHASES OF SKILLS ACQUISITION
Basic Principle
Technical prociency in the OR is a continuous process
of improvement. Stages of achieving mastery have been
described by Dreyfus and Dreyfus,6 proceeding through a
logical process of acquiring both awareness and skill:
Unconsciously incompetent
Consciously incompetent
Consciously competent
Unconsciously competent
The logical school of epistemology distinguishes
between awareness and knowledge. The learner begins
both unaware and ignorant. Awareness (consciousness)
and competence (technical prociency) are distinct phe-
nomenon and can be analyzed in a 2 2 matrix (Fig.
21) or as a linear progression leading to mastery, as listed
previously. Regardless of the task, the nave learner ini-
tially has no idea of the complexity of the task, because it
looks relatively easy when demonstrated by a master. All
Figure 21 The progression to mastery is a logical transition
involving both awareness and competence. In order to effectively
teach surgical skills, the expert must regress to the consciously
competent stage.
17
of us remember our rst attempt at sewing the skin and
our nearly ballistic trajectory of the needle once freed from
the resistance of the skin. Our lack of appreciation of how
to brace our hand and check the movement of the needle
quickly converted our nave condence and helped take
us to the next and essential step of consciously incom-
petent when we realized that sewing the skin was much
harder than it looked.
With practice, the learner becomes consciously compe-
tent. He or she can perform the task but must focus,
concentrate, and pay careful attention. After years of
experience and hundreds of repetitions, the surgeon may
become unconsciously competent as her or his body
becomes one with the surgical instruments and he or she
reaches what has been described as the autonomous
phase of skills acquisitionlike the experienced driver
who gets in the car and drives to work, hardly conscious
of the thousands of steps taken en route and taken for
granted.
Practice
Practice, practice, practice is an essential element of achiev-
ing mastery. However, practice alone is not enough as
espoused by the great football coach Vince Lombardi who
stated, practice does not make perfect. Perfect practice
does.6a Implied in that wisdom is the essence of coaching
and teaching. A good instructor not only must be a master
but also must appreciate the method and the steps in
helping the learner achieve prociency. The operative
teacher must guide the initial attempts, providing feed-
back in real time to the learner. Often, words cannot
describe the exact movement desired. To do so involves
a considerable transference of motor knowledge to verbal
instructions in terms that the learner can understand.
Often, a demonstration is necessary, even at the risk of
alienating an overcautious resident who fears he or she
will lose the case. Done with political sensitivity, a dem-
onstration can be very effective. If a picture is worth a
thousand words, a demonstration is worth a million.
Independent practice is essential in helping the learner
progress toward unconscious competence. The repeated
practice of a technique in a relatively nonthreatening envi-
ronment is as important as the real-time feedback that
guides the initial attempts of the learner in the consciously
incompetent stage. But to progress to a consciously com-
petent level, the trainee must have the opportunity to
practice in an environment devoid of the discerning eye
and constant critique of the well-meaning but often over-
vigilant attending, which often results in an excess degree
of performance anxiety. Inherently entangled in this quest
is the dilemma of how one can achieve a system of
graduated responsibility and, at the same time, ensure
the competence of the learner. The increased presence of
attendings required by modern reimbursement and super-
vision policies creates a constant threat to this critical facet
of the surgeons training. The challenge requires a very
 18 SECTION I: GENERAL CONSIDERATIONS
intimate relationship between the teacher and the learner
so that direct, observational instruction can gradually fade
as the resident becomes more adept. The titration of the
teaching surgeons involvement is surely a delicate balance
that requires careful assessment of not only the learners
technical ability and judgment but, equally important,
their honest self-awareness of their limitations. It is critical
that they recognize when they need help and to call for
it in a timely fashion. If medicine is indeed an art, then
surgical instruction is the distillation of medical education
to its absolute essence.
Example: Lack of Autonomous Awareness
The chief resident is left in the OR to close with the junior
resident after completion of the procedure. The attending
goes out to talk with the family. When coming back in,
the counts are correct: Two days later the patient is
found to have vague abdominal pain and a plain X-ray
shows a malleable retractor left in the abdominal cavity.
Although the chief resident is felt to be unconsciously
competent at this stage of training, even minor distrac-
tions can lead to signicant errors.
Alternative Scenario
The resident, in accord with hospital policy, requests that
an x-ray of the operative eld be done before the patient
is undraped and awakened. The retractor is recognized.
Several fascial sutures are removed and the retractor
retrieved. The attending waits until the resident noties
her or him before visiting with the patients family in the
waiting room.
Discussion: Many safeguards have been employed to
ensure that the operation is as safe as possible and that
such unexplainable misadventures like retained instru-
ments, wrong-side surgery, and transfusion reactions are
avoided. Simple methods such as marking the patients
surgery site with an indelible marker in the preoperative
holding area, time-out recitation of the operative
consent, and positive identication of the patient are
simple and effective ways of ensuring that the operation
is as safe as possible. New technologic innovations such as
radiofrequency chips on laparotomy sponges and routine
postoperative x-ray examination of the operative eld have
become commonplace in many hospitals. Notication of
the patients family after the operation is extremely impor-
tant, but this should not be done until one is absolutely
sure that the operation is indeed over and the patient is
doing well.79
TECHNICAL TIPS: BECOMING AN
AWARE INSTRUCTOR
Parallax
We all remember our favorite instructors in the OR and
we will never forget those who could turn a simple pro-
cedure into a nightmare. What distinguished these masters,
usually later in their career, from the overanxious and
impatient younger attendings? The masters were able to
do anything and they could teach you in a manner that
was calm, effective, and enjoyable. They could see things
from your perspective. They could appreciate when you
could run free and when careful attention was needed.
They appreciated parallax, dened as the difference in the
appearance of an object when seen from two different
vantage points not on a straight line. When operating on
many midline structures, the resident surgeon and the
attending/instructor typically stand on opposite sides of
the table, with the surgical site between. Their vantage
points are often 90 different. As a consequence, they
often see very different elds. During an open cholecys-
tectomy, the gallbladder, when viewed from the right side
of the table, is partially hidden from the residents view
under the edge of the liver but is in plain view of the
teaching assistant on the patients left. Failure to appreci-
ate this difference can lead to catastrophic technical errors.
Similarly, exposure and retraction must be presented to the
residents view from the opposite side of the table (Figs.
22 and 23). Correctly done, this often negates the clear
view of the teaching assistant who must have the insight
and condence to allow the residents dissection. Failure
to show and expose the eld adequately and accurately
can lead to trouble.
Example: Lack of Appreciation of Parallax
A particularly difcult laparoscopic cholecystectomy is
converted to an open procedure. The triangle of Calot is
densely adherent to the infundibulum of the gallbladder.
The residents view of the base of the gallbladder is dif-
cult because the patient is obese, the wound is deep, and
the distended gallbladder and liver edge partially obstruct
the view of the cystic duct. The attendings view, in
contrast, is clearer and affords the view of a thin but
discernable plane between the infundibulum and the
Figure 22 Residents view of the gallbladder from the patients
right side. The gallbladder is barely visible and obscured by the
wound edge, retractor, and lap pad.
 2 TEACHING TECHNICAL SKILLSERRORS IN THE PROCESS
Figure 23 The attendings view from the patients left side. The
gallbladder is obvious and in plain view.
immediately adjacent common duct. Frustrated with the
residents hesitancy and faint-hearted attempts at dissec-
tion, the attending urges the resident to cut, cut. Unsure
but willing to please, the residents Metzenbaum scissors
skate off the distended gallbladder and lacerate the
common duct.
Discussion: The residents view of the operative eld
(see Fig. 22) can be drastically different from that of the
attending across the table (see Fig. 23). Because more
biliary surgery is done in the two-dimensional view
afforded by a video screen, familiarity with open proce-
dures is rare. In addition, only the most difcult cases
default to the open method. Dissection in difcult, deep,
and challenging cases can be treacherous, not only for the
resident but also for the recently trained attending who
likely has minimal experience with open biliary surgery.
Anatomic structures in the surgical eld that lie under-
neath the incision and in close proximity to critical struc-
tures are particularly dangerous: for example, the common
bile duct in cholecystectomy for cholecystitis and the
ureter in colon resection in diverticulitis. Appreciation of
the principle of parallax and patience with the less experi-
enced resident is of critical importance in achieving a safe
outcome.
Bracing
Basic Principle
Bracing is one of the simplest techniques to help the
neophyte achieve a greater deal of prociency. It is based
on the physics of a lever that consists of a long, rigid
structure resting on a fulcrum. The lever has two compo-
nents: the level arm and the moment arm. The placement
of the fulcrum, or brace point, close to the object to be
dissected helps amplify the strength of the lever and
dampen the effects of the movement of the lever arm. The
longer the moment arm, the more amplication of the
movement of the lever arm. Moving the brace point closer
to the target minimizes the moment arm, dampens the
19
natural tremor that we all have, and increases the power
and control of the instrument.
Several trips to the dentist for teeth cleaning can help
one better understand the importance of bracing. Dentists
and dental hygienists know that a typical molar has 32
different and distinct surfaces. The cleaning, drilling, and
lling of a tooth demands precision in fractions of a mil-
limeter. An inexperienced hygienist will typically skate
off the surface of the tooth and impale the patients gums
with the instrument. In contrast, the experienced hygien-
ist or dentist never takes the heel (or hypothenar emi-
nence) off the patients chin, carefully bracing and checking
each stroke of the instrument. Movements are careful,
controlled, and precise because of the focused attention
to bracing.
In surgery, bracing has both a micro and a macro appli-
cation. Microbracing is an essential skill in microsurgery,
dentistry, and vascular surgery in which the eld is small
and the tolerances measured in fractions of millimeters.
Microbracing requires moving the fulcrum closer to the
point of action, minimizing tremor, and affording precise
control of the instrument. It helps avoid past pointing
once the resistance of the tissue is passed. Bracing is
facilitated by having the OR table at the correct height,
which in most cases should be at the surgeons elbow.
Adjusted so, it will allow the surgeon to rest the forearm
on the patient or the heel of the hand on the edge of the
wound. With the wrist locked and a predictable angle of
the needle on the needle holder, one simply supinates the
forearm to scribe the needle in a controlled, smooth arc
through the tissue. The nondominant forearm is held at
a right angle to the other, and the forceps is ready to assist
the manipulation of the tissue or accept the needle when
appropriate (Figs. 24 and 25).
Macrobracing is critical in those maneuvers that take
considerable strength to penetrate tissue with marked
resistance such as the chest wall when placing a chest tube
or the placing of wire sutures through the sternum. The
surgeons legs are slightly bent at the knees, the upper
body is locked in place, engaging the core, the elbows
are tucked against the torso and/or on the iliac crest, and
both hands are held rmly on the instrument. One hand
(the dominant) provides the necessary forward force while
the other checks the movement of the instrument after
the resistance of the tissue is overcome. One hand is the
gas, the other is the brakes.
Example: Failure to Brace and Control Movement
An intern is asked to place a chest tube in a victim of a
motorcycle collision, a 250-pound man in acute distress.
The chest wall is thick and muscular, making the dissec-
tion difcult. Having placed a tube only in a simulator,
the intern is unaware of the great degree of force necessary
to penetrate the dense intercostal muscles. As the Pean
clamp nally penetrates the chest wall, the intern is equally
unprepared for checking its forward motion. The clamp
continues through the diaphragm and into the spleen.
 20 SECTION I: GENERAL CONSIDERATIONS
Figure 24 Lack of bracing. The residents fulcrum, or brace
point, is the scapulothoracic junction.
Figure 25 Maximal bracing. Forearms and hands resting on the
eld and held at 90.
Simplifying Movement
Simplifying movement, like bracing, is mostly a matter of
physics. In performing a controlled and repetitive move-
ment, the fewer muscles and fewer joints that are utilized,
the better the control and the less fatigue due to use and
overuse of unnecessary muscles. When sewing, the wrist
is locked and the only movement necessary is supination
of the forearm. The needle scribes a smooth, atraumatic,
and predictable arc through the tissue. The needle should
remain in place when released as no additional strain or
torque is applied during its placement. As a result, the
needles location, even when obscured by a bloody eld,
should be predictable and easily retrieved by merely
repeating a similar movement aimed just beyond the
rst.
Example: Lack of Simplifying Movement
The morning after a challenging Whipple procedure
for severe chronic pancreatitis of the head and uncinate
process in a patient with pancreas divisum, your chief
resident is unable to open the jar of ointment to apply to
the clinic patients burn wound owing to extreme soreness
and spasm of his or her neck and upper back muscles. The
cumulative effect of the repeated movement and static
posture of the challenging 10-hour operation have taken
their toll owing to their lack of bracing and simplication
of movement.
Visualization
Visualization, or seeing with the minds eye, further
facilitates the smooth, careful application of the instru-
ment on the patients tissues. Used by athletes who
rehearse their complex routines in their mind at the top
of the slalom skiing course or at the edge of the gymnas-
tic apparatus, it helps set a mind map of the complex
movements to follow. Visualization also helps the surgical
trainee develop an awareness of the underlying anatomic
structures to be either incorporated (like the submucosa
in a Lembert stitch of the bowel) or avoided (like the
parotid duct when suturing a facial laceration). A favorite
senior resident, who was also a student of martial arts,
once remarked: It is a very Zen thing. Your whole con-
sciousness should ride the tip of the needle as it arcs
through the tissue. Or as Yoda, in the Star Wars trilogy,
admonished his student: See with your mind, Luke, not
with your eyes.
Example: Lack of Visualization
During a laparoscopic cholecystectomy, the resident fails
to appreciate the proximity of the right hepatic duct
posterior to the cystic duct/infundibular junction owing
to their overlapping nature. Unfamiliar with how move-
ment of the gallbladder with the opposite hand and
turning of the 30-angled scope can help reconstruct a
 2 TEACHING TECHNICAL SKILLSERRORS IN THE PROCESS
three-dimensional image, the residents attempts to dissect
the triangle of Calot results in injury to the right hepatic
duct, which lies immediately posterior to the cystic duct.
POSTOPERATIVE PITFALLSTHE
AFFECTIVE DOMAIN OF LEARNING
Basic Principles
Feedback has been described as the currency of adult
learning. Without providing learners incremental guid-
ance to improve their skill, their practice may result only
in the perpetuation of bad habits or the extinction of good
ones. It is only with feedback that we can most efciently
guide initial attempts and add encouragement as they
demonstrate progress. The basic principles of feedback can
be easily remembers with the pneumonic, TENDS to be
both positive and negative:
T timing
E environment
N nonjudgmental
D based on direct observation
S specic information should be both positive and
negative
Entire books have been written on how to provide
feedback in any educational or supervisory setting. There
are many barriers to doing it well. We all want to be liked
and are typically uncomfortable in confronting and cor-
recting others. Leveling harsh criticism (often confused
with negative feedback) may seem inappropriate at the
time because of the presence of others. However, feed-
back must be given in a timely fashion to be effective.
Barring other obstacles, sooner is better than later. Serious
negative feedback is best given in private. The OR is
always staffed with an entire team, and extremely harsh
words can negatively affect all within earshot. One effec-
tive technique useful in giving timely but important neg-
ative feedback in the OR is to quietly invite a particularly
surly or uncooperative resident over to the x-ray board
and, while feigning explanation of the lm, speak in a very
quiet, but rm, unmistakable manner. You can then relate
your displeasure with their attitude, lack of skill, or prep-
aration and set denite guidelines for their continued
participation in the case.
Feedback should be nonjudgmental. It should be about
objective behaviors, not based on your opinion of why
something was done or character aws suspected in the
learner. It is much better to state that I am disappointed
in your lack of preparation for the case, rather than
calling the resident lazy. Likewise, it is best to limit your
feedback to those behaviors or actions that you yourself
witness rather than relying on hearsay or rumor. As a
program director or administrator, it is critical to have on
hand any written documentation previously submitted by
others during a feedback session. In such formal sessions
and in other ad hoc sessions in real time, the feedback
21
should always be specic: a particular technical maneuver,
action, or omission. It should precisely dene your expec-
tations and the manner in which you expect the learner
to change.
Technical Feedback
Technical feedback is a bit easier and less emotional in
nature and, consequently, easier to impart. As Bosk, in his
famous treatise on surgery training, Forgive and Remem-
ber1 observed, technical errors due to lack of experience
are the most forgivable of all errors. In the OR, a little
humor to lessen the blow on the residents ego can some-
times go a long way. One of my most effective attendings
once described my feeble attempts to incise the linea alba
as the Cuisinart technique. The message was clear, but
kind and in good faith.
In order to provide effective technical feedback, it is
critical for the instructor to be able to see the procedure
from the learners perspective and relate in words the exact
movement or technique desired. It is often extremely dif-
cult to describe in precise words our intent. Transference
of our motor memory into words that can be understood
by the learner can often fall short of its mark and be con-
fusing and subsequently frustrating for both the instructor
and the learner. When faced with that frustrating conun-
drum, we often resort to a demonstration. To be an effec-
tive learner and recipient of feedback, residents must be
condent enough to receive the help rendered by the
demonstration and not fear they are losing the case.
Such fears are heightened if the demonstration is exces-
sively long. Used sparingly, demonstration of a technique
can be extremely helpful. Again, if a picture is worth a
thousand words, a demonstration can be worth millions.
Feedback on technique must be done in real time
and done almost continuously during the conduct of the
operation as each movement is performed. A summative
or global critique after the operation should emphasize
general trends or tendencies that are both positive and
negative. The attending should discuss not only areas for
improvement but also things that the resident did par-
ticularly well. The well-known sandwich technique,
espoused by Blanchard in his classic primer, The One
Minute Manager, is a helpful strategy. The feedback
session should begin with a positive comment such as
acknowledging the residents persistence, followed by
citing specic examples of where improvement is needed.
Finally, it is best to end with the other bread of the
sandwich, a positive acknowledgment and encouraging
remark to help motivate the resident to persist in her or
his efforts to improve.
Feedback and Acknowledgment of the Operative Team
Surgery is a team sport that has many members. Most of
this discussion has centered on a teaching environment,
but regardless of the setting, either in a teaching hospital
or in private practice, the other players on the team should
be acknowledged. First and foremost is the patient. It is
 22 SECTION I: GENERAL CONSIDERATIONS
often helpful to stand by and reassure, as much as possible,
the patient as he or she emerges from anesthesia. It is
important to thank the rest of the team, the anesthesiolo-
gist, nurses, and technicians, for their help. Any problems
that arose should be addressed in a kind and objective but
clear manner. If necessary, more serious matters requiring
negative feedback can be discussed in private.
Feedback is typically sparse in the immediate postop-
erative period because the patient in the recovery room is
affected by the amnesic properties of many of the anes-
thetic agents and other medications. Writing of the orders
and dictation of the operative note are also important to
accomplish promptly. As soon as possible, one member of
the team, typically the most senior, should speak with the
patients family. The hours spent in the waiting room
while a loved one is undergoing an operation are some of
the longest in ones life. The rst words that should come
out of your mouth is that the patient is ne or, less fre-
quently, they are in some degree of danger. Until family
members hear that the patient is well, they assume the
worse. The referring physician or primary care provider
should also be promptly notied, updated, and advised of
any condition that might complicate the recovery period
and should be graciously thanked for allowing you to
participate in the care of their patient.
Attention to all involved in the operation will help build
a sense of teamwork and camaraderie with your col-
leagues both in and out of the OR and ensure that your
next operation will more than likely be as successful as
possible.
REFERENCES
1. Bosk CJ. Forgive and Remember: Managing Medical Failure,
2nd ed. Chicago: University of Chicago Press, 2003.
1a. Accreditation Council for Graduate Medical Education
(ACGME). Program requirements for graduate medical
education in surgery, January 1, 2008. Available at http://
www.acgme.org/acWebsite/downloads/RRC_progReq/
440_general_surgery_01012008.pdf
2. McGreevy JM. The aviation paradigm and surgical educa-
tion. J Am Coll Surg 2005;201:110117.
3. Romfh RF, Cramer FS. Technique in the Use of Surgical
Tools, 2nd ed. Norwalk, CT: Appleton & Lange, 1992.
4. The Southern Surgeons Club. A prospective analysis of
1518 laparoscopic cholecystectomies. N Engl J Med
1991;324:10731078 [published correction appears in N
Engl J Med 1991;325:15171518].
5. Bell RH. Surgical Council on Resident Education: a new
organization devoted to graduate surgical education. J Am
Coll Surg 2007;204:341346.
6. Dreyfus HE, Dreyfus SE. Mind Over Machine. New York:
New York Free Press, 1982.
6a. Phillips DT. Run to Win. New York: Macmillan, 2002;
p 95.
7. Gibbs VC. Patient safety practices in the operating room:
correct-site surgery and nothing left behind. Surg Clin
North Am 2005;85:13071319.
8. Dagi TF, Berguer R, Moore S, Reines HD. Preventable
errors in the operating roompart 2: retained foreign
objects, sharps injuries, and wrong site surgery. Curr Probl
Surg 2007;44:352381.
9. Blanchard K, Johnson S. The One-Minute Manager. New
York: Harper Collins, 1982.
3
Legal Considerations
Catherine Bertram, JD and Stephen L. Altman, MD
INTRODUCTION
As trial lawyers with over 50 years of combined experience
we urge you to invest the time it takes to read this chapter.
Then, make a commitment to change your practice to
consent patients correctly. Top surgeons understand that
effective communication with their patients is a skill that
needs to be updated and rened over time just like surgi-
cal technique. Proper consent does not require more time
when you understand the true nature of an adequate
consent.
LEGAL PITFALLS IN SURGICAL
CARE BEFORE ENTERING THE
OPERATING ROOM
Let us start by emphasizing the key point of this chapter
informed consent is a process. It is not a hospital-
generated form. Surgeons make a critical error when they
assume that getting a patient to sign the hospitals consent
forms means that they have complied with the require-
ments of informed consent. This error can be quite costly
to your practice and to your reputation.
Consent is a process that requires communication
between the surgeon and the patient. Usually, it is a two-
step process that starts during the ofce visit and contin-
ues at the hospital before surgery. The ofce visit is your
opportunity to take the time to explain the proposed
surgery, the risks and alternatives, and the consequences
of not proceeding. Thus, patients have time to reect on
all the information you have given them and can really
make an informed decision to proceed with the surgery
you suggest.
The time for having that discussion is not in the hallway
of the same-day surgery unit while you are trying to get
in the rst case of the day. That is not fair to you or to
the patient and is certainly not the best use of your time.
Patients can feel pressured to agree and will often say they
were so worried about the surgery that they did not even
listen or that they signed the forms just to get things
moving without having time to ask questions or to reect
on the complex decision they were asked to make.
In most hospitals, the surgical consent form is executed
right before surgery. This is a good practice because it
provides some evidence that the patient consented to
surgery. However, in most states, that form alone is not
sufcient to establish that you met your duty to your
patient.
We have both seen surgeons mismanage their relation-
ship with their patient and their family in ways that have
led to medical errors, an omission through miscommuni-
cation, or claims from patients that the surgeon failed to
provide them with sufcient information to make an
informed decision about surgery: Here are three ways we
have observed: (1) the surgeon acted as an all-knowing
being; (2) no ofce notes were kept about the consent
discussion or the refusal of care; (3) the surgeon did not
tell the patients about who would assist with their
surgery.
Surgeon as All-Knowing Being
If you have this aura and express it to your patients, then
this is what they will expect. If you tell the patients
what surgery they need and just assure them that
everything will be ne, then you have taken com-
plete responsibility for the decision making as well
as the outcome. No wonder the patient (and the
jury) will want to hold you 100% responsible for any
negative outcome.
Practice Pointer. Communication and decision making
are a two-way street. Patients have responsibilities along
with their rights. Share these responsibilities with the
patient. Make the patient part of your health care team.
Here are some ways to do that:
Have brochures in your ofce that explain ofce hours,
after-hours call procedures, what to do in an emer-
gency, and who to call in your ofce if they are having
problems after surgery. Tell them whether they are
responsible for bringing their lms to the hospital.
Also, the brochure can outline their role in follow-up
after getting laboratory tests, diagnostic tests, espe-
cially from outside providers. Make sure they under-
stand how to get to you if they think they are having
a complication and need to be seen. If others will take
calls for you, explain how that works.
Use American College of Surgeons or other
specialized brochures, videos, and computer-
 24 SECTION I: GENERAL CONSIDERATIONS
generated educational materials to supplement
your discussion with patients regarding the
alternatives, risks, and benets of the surgery you
propose. Also direct them to websites that you think
are accurate for basic information, if appropriate. You
can provide a fact sheet that explains in detail why the
surgery is performed, the alternatives, the risks, and
what to expect after surgery. This can be handed out,
not as a substitute for discussion, but as a supplement.
Your staff can use a checklist to conrm that the patient
received the materials. Whereas this is not a substitute
for discussion, it certainly helps support your argument
that the patient was thoroughly informed about the
surgery before the big day!
If you send a patient for a magnetic resonance imaging
(MRI) scan at an outside facility and they need to come
back to discuss results, the order for the MRI should
include a section that reminds them that it is their
responsibility to obtain the lm and obtain a follow-up
appointment. Many surgeons have the patient sign this
acknowledgment. That is a good way to communicate
that the patient is sharing responsibility for the imple-
mentation of the plan of care.
No Ofce Notes about the Consent Discussion
or the Refusal of Care
A surgeons note, timed and dated contemporaneously
with the event, is the best way to avoid subsequent allega-
tions regarding lack of informed consent. Surgeons often
fail to document the most important part of a discussion
when a patient refuses care. The key part to document is
that you told them the potential consequences of their
refusal. A patient cannot make an informed decision about
whether to have a surgery or a major diagnostic test without
weighing what might happen if they do not have it.
Example: Told the patient that the lump was probably just
a cyst but told her to go and have a mammogram.
It is easy to understand if the patient later says, I trusted
Dr. Smith when she said it was just a cyst, so it didnt
seem necessary to have the mammogram.
Practice Pointers. Make sure that you document not
only the fact that you had a discussion about the surgery
but also that you reviewed the risks, alternatives, and likely
outcome if nothing was done. The note should state that
the patient understood your explanations and that all
questions were answered.
If the patient has any additional risks or conditions that
make the surgery more risky, you need to document
that portion of the discussion more extensively.
When the patient refuses or seems like she or he is not
going to have the surgery, you need to add details
about your explanations of the risks of delay and the
consequences of no treatment. This is often a good
time for a follow-up letter to the patient, sent by certi-
ed mail.
Not Telling Patients about Who Will Assist
You with Their Surgery
In general, patients will appreciate and understand that
you cannot perform the surgery by yourself, but in most
circumstances, you have a duty to explain who will be
involved and what the assistants will be doing.
Patients will also understand that sometimes others,
including vendors and technical people, need to be present
to assist with device placement. It is your job to make sure
the patient agrees to that.
Failing to explain these facts can result in claims for
fraud or battery. You may also get testimony in a malprac-
tice case that the patient never consented to having a
resident do certain portions of the surgery.
Practice Pointers
If you are in a teaching hospital, you must explain what
the residents role will be and document that you had
this discussion with the patient.
If you are in a community hospital, you must explain
who will be assisting you with surgery and what they
will be doing. Document that discussion.
If vendors or others will be present, the patient has a
right to know and needs to consent.
Some hospital consent forms include general language
regarding assistants and others in the operating room,
but you are the person that the patient agreed could
perform the surgery, not others, so make sure the
patient is clear about the role of others.
These are fairly simple, straightforward concepts that
need to be incorporated into your practice to make certain
the patient is provided with all the facts before he or she
consents to surgery.
LEGAL PITFALLS IN SURGICAL CARE
AFTER THE OPERATING ROOM
Murphys Law: If anything can go wrong, it will. When
Murphy developed his law, he must have been partially
thinking about health care providers. What else could
explain why doctors and other health care personnel spend
countless hours talking with patients about things that
might go wrong during treatments and procedures? Why
else are entire books like this written about surgical pitfalls
if adverse outcomes do not actually occur? Whether a
doctor is just nishing a residency program or is getting
ready to retire, every doctor should know that you do not
need to commit medical malpractice to get sued, you just
have to have an unhappy patientand nothing, we repeat,
nothing, can make a patient or family more unhappy than
an unexpected surgical complication.

Part of the problem and shock can be ameliorated with
a good, complete, preprocedure informed-consent discus-
sion. That topic has already been dealt with in this chapter.
Unfortunately, even the best informed-consent conversa-
tion or document, by itself, may not be enough to prevent
a malpractice suit from being led. You are lucky, however,
because when an adverse outcome occurs, you have a
second chance to prevent a lawsuit from being led or, if
it is destined to be led, to improve your chances of pre-
vailing. Although most of these are common sense sug-
gestions, in 30 years of litigating hundreds of medical
negligence cases, we have both come to appreciate that
common sense does not always rule when a serious injury
or death occurs. Thus, a bit of repetition may prove
helpful.
DOS AND DONTS
Dont stop seeing or decrease the frequency of visits
with your patient or your patients family. When prob-
lems occur, this is the time for you to be the most
visible. We cannot begin to tell you the number of
depositions we have taken in which the patient or
the family complains that Dr. X never seemed
to be around to answer our questions after the
surgery or I never saw Dr. X for the several
days between the surgery and the death of my
husband. Rather than making the heart grow fonder,
absence will make the patient or the family think that
you do not want to face them and explain what occurred.
We have known doctors who have called subsequent
treating physicians to simply inquire about how the
patient is doing and made note of those conversations
in their ofce charts.
Do make sure that the family of the patient knows of
your concern over what occurred. It is not an admission
of liability to express condolences over death or to let
a patient know that you are sorry they have suffered a
complication. We have even known of surgeons who
attended funerals of patients who died after a surgery.
To ignore a problem leads the patient or the family to
think you do not care. If a patient thinks you do not
care about her or his welfare, you are much more likely
to be included in any litigation. Remember, the general
rule is that people do not sue people they like. The
authors are frequently amazed at the number of times
potential defendants in malpractice litigation are not
sued even though a real question exists about whether
their actions were a deviation from the standard of care.
This topic is usually explored at deposition only to learn
that the patient simply did not want to sue Dr. X
because the patient liked him or her.
Dont try to explain what occurred until you are
sure of your facts and until your conclusion can
be corroborated. Obviously, you are going to be ques-
3 LEGAL CONSIDERATIONS 25
tioned immediately by the patient or the family about
what occurred. You will need to describe to them, from
a factual standpoint, what you know up to that point.
Just refrain from making conclusions as to the cause of
problems. In most instances, you would not try to
make a diagnosis without adequate data. Why do it
now? The admonition not only applies to direct con-
versations with patients but also to documention. In a
recent obstetric case, a baby was transferred to the
neonatal intensive care unit (NICU) for a brachial
plexus injury postdelivery. The neonatologist, who
should have known better, reported that he was dealing
with a newborn with an obvious brachial plexus injury
caused by excessive traction. Not only was that con-
clusion shared with the parents in the following days,
it was repeated during the pendency of the litigation.
In fact, the defendant doctor vigorously denied that
excessive traction was used, and had evidence to support
that defense. The family and their attorney kept arguing
that even the neonatologist concurred that negligence
had caused the injuries at birth. It would have been a
simple matter for the neonatologist to write obvious
brachial plexus injury, cause unknown at this time.
Similarly, in a recent laparoscopic appendectomy case
on a 20-weeks pregnant patient, a general surgeon
wrote, in a nonperforated appendix procedure, that
upon entering the abdomen, I saw purulent uid
around the appendix. What he really saw was a whitish
exudate and not purulent uid because there was no
source for the purulence in this nonperforated appen-
dix simulation. Weeks later, the patient developed an
infection after a spontaneous abortion, and the surgeon
was sued for not starting antibiotics in the presence of
purulence. The entire lawsuit, over 7 trial days, could
possibly have been averted had he simply written that
he visualized a white substance around the appendix
rather than calling it purulence, especially because he
had no information that it was.
Do make complete records whenever an adverse
outcome occurs including as much factual information
as you can recall. The plaintiffs attorney may argue that
you are attempting to create a defense, your attorney
will counter by arguing that you were attempting to
facilitate the investigation or understanding of what
occurred by providing the most detail possible. Any
entry along these lines should be correctly dated and
timed, so that there is no argument that someone was
attempting to alter their records.
Dont ever, ever, alter your records. Even if your alter-
ation, deletion, or addition is perfectly innocent, it will
never appear that way. If, after an adverse outcome,
you are found to have made a change to an existing
record, that patient, their family, and most important,
the jury will automatically assume you were attempting
to delete a harmful notation and will not believe a word
you say. Statistics tell us that approximately 70%
of all medical malpractice cases that go to trial
 26 SECTION I: GENERAL CONSIDERATIONS
end up favorably for the health care provider.
Clearly, that means that cases are won even in cases in
which signicant injuries or death occurs. You can talk
your way out of a bad outcome. You can never talk
your way out of a lie.
Do carefully read chart entries after an adverse outcome
occurs and be sure to properly and timely note any
disagreements you might have with the charted
information. We know what you are thinking right
now. You simply do not have time to read entries that
should have been accurately charted by residents, col-
leagues, or consultants. Take the time. If you make
your disagreement known contemporaneously with
your review of the note, you can argue that there was
a legitimate disagreement. Many of you sign off on
notes written by others. A smart plaintiffs attorney will
start by getting you to agree that your countersignature
on a note is your statement that you agreed with what
was written. As you can see, making your disagreement
known 2 years later, when you are in the midst of a
malpractice case, will cause you to look like you are
manufacturing a defense because you have already
agreed that your signature is your statement that you
agreed with the note. It will be further argued by your
opponent that you now recognize how harmful that
fact or comment is to your defense and that any reason-
able doctor would have corrected that mistake earlier
if, in fact, a disagreement really existed.
Dont ignore legitimate requests for medical records
by a patient, a family member, or an attorney represent-
ing the patient. In many states, the time to respond to
these requests and the amount that can be charged are
governed by statute. To ignore this type of request or
to take too long to respond will cause the person
making the request to question why the records were
not sent and will again raise the specter that you are
attempting to hide something. The records, in their
entirety, should be timely copied and mailed, along
with an appropriate letter, inquiring as to whether there
is any other way you might be of assistance and again
inquiring into the health of the patient or to pass along
your sympathies. In another recent general surgery
matter involving a failure to timely diagnose and treat
a breast mass, the surgeon was accused of withholding
information and falsifying his records when his ofce
took months to send out records, did so in a piecemeal
fashion, and never sent out all the records. The case,
ultimately won by the surgeon, could have been tried
in a few days with the central issued being standard of
care. Instead, the surgeons credibility became the
central issue, and days were wasted calling present and
past employees about record keeping and responding
to record requests.
The lists of Dos and Donts goes on forever and is far
too numerous to cite, in its entirety, here. When you are
faced with that inevitable, adverse outcome and you are
questioning how you should be handling a particular
situation, always ask yourself this question: How would
my patient or a jury view my actions? Your choice might
just be the thing to keep you from being sued or the exact
thing that helps you win.
4
Preoperative Pitfalls
Aimee M. Crago, MD, PhD and
Stephen R. T. Evans, MD
INTRODUCTION
Although the hospital course of a patient is affected pro-
foundly by what happens inside the operating room, many
complications can be prevented by adequate preoperative
preparation. Rates of postoperative myocardial infarction,
decomposition of congestive heart failure, pneumonia,
bleeding, and infection are all affected by identication of
a patients individual risk factors and medical optimization
of the patients condition prior to surgery. A clear history
and physical examination, reconciliation of a patients
medication list, and consultation with appropriate special-
ists are the rst steps in ensuring that an operation will go
as smoothly as possible, and that hospital length of stay
and preoperative morbidity and mortality rates are main-
tained at a minimum.
INDICATIONS
The surgeon should complete a mental, if not physical,
checklist of preoperative risk factors and appropriate inter-
ventions for each patient who is scheduled for the operat-
ing room. There are no exceptions to this dictum. Even
in emergent situations, knowledge of the patients comor-
bidities should be elucidated as soon as possible to aid in
intraoperative and postoperative care.
PREOPERATIVE STEPS
Step 1 Neurologic evaluation and assessment of pain
susceptibility
Step 2 Cardiac risk assessment and preoperative
optimization
Step 3 Pulmonary risk assessment and preoperative
optimization
Step 4 Screening for advanced liver disease
Step 5 Assessment of renal function
Step 6 Assessment of infection risk and wound healing
ability
Step 7 Assessment of nutritional status
Step 8 Assessment of bleeding risk and identication of
the hypercoagulable patient
Step 9 Identication of endocrine dysfunction
Step 10 Documentation of the family history
PREOPERATIVE EVALUATION
Neurologic Evaluation and Assessment of
Pain Susceptibility
Failure to Recognize Carotid Disease
Consequence
The incidence of ischemic stroke ranges from less than
1% for elective surgery procedures to as much as 10%
in postcoronary artery bypass graft (CABG) patients
with concurrent carotid disease.1
Grade 4/5 complication
Intervention
Therapy for patients after cerebrovascular accident
(CVA) is mainly supportive, centering on blood
pressure control and rehabilitation to maximize func-
tional outcomes. More aggressive therapy in the form
of intra-arterial thrombolysis may be considered only
in the rst hours after stroke. Functional outcomes with
thrombolysis appear similar to those seen in nonopera-
tive stroke victims. Retrospective studies do, however,
show a 25% chance of surgical site bleeding. Mortal
complications have been reported with thrombolysis
after craniotomy, so this treatment should not be
employed in this population.2
Prevention
The low incidence of stroke in postoperative patients
without history of transient ischemic attack (TIA) or
CVA means that preoperative screening of the asymp-
tomatic patient is likely unwarranted. However, rates
of CVA increase in the general surgery population with
symptoms and are noted to range from 3% to 4% in
those with a known carotid stenosis or positive history.
Similar outcomes are seen in patients undergoing major
 28 SECTION I: GENERAL CONSIDERATIONS

Table 41 Alternative to Intravenous Narcotics in the

Prior stroke?
Postoperative Patient
Yes No Drug Contraindications/Side Effects

Nonsteroidal anti-inammatory Renal dysfunction/acute renal

Carotid ultrasound Yes Symptoms of carotid disease? drugs (e.g., ketorolac) failure

Dextromethorphan Seizure, arrhythmia, brain damage

Cyclo-oxygenase 2 inhibitors Cardiovascular disease, renal

dysfunction/acute renal failure,
Greater than gastrointestinal bleeding
60% stenosis? No
Acetaminophen Hepatic dysfunction
Yes No Neurontin Somnolence, dizziness, fatigue

Local anesthetic Seizure, arrhythmia

Carotid
OR Ketamine Psychotropic effects
endarterectomy

Peripheral nerve block Seizure, arrhythmia

Figure 41 Algorithm for preoperative evaluation for carotid
disease.
vascular surgery.3 It seems prudent, therefore, that
carotid endarterectomy (CEA) should, where possible,
precede elective general or vascular surgery proce-
dures in patients with known cerebrovascular disease
(Fig. 41).
This recommendation would be concordant with that
applied to patients with carotid disease and requiring
coronary artery revascularization (CABG). Debate still
exists as to the timing of CEA versus CABG, but in the
setting of asymptomatic coronary artery disease (CAD),
the carotid is addressed rst to decrease the rate of CVA
at the time of CABG (10%5.3%). Conversely, risks of
comorbid cardiac disease must be considered in the
context of asymptomatic carotid disease, because delay of
coronary revascularization to allow recovery from CEA
leads to an increase in overall mortality (9.4%) despite low
rates of stroke.4 The possibility of concurrent CEA and
CABG has been explored, but its role is controversial.
Failure to Recognize Low Pain Threshold
Consequence
Tachycardia, pneumonia, and opioid withdrawal are
consequences of failure to recognize low pain thresh-
old. Chronic pain patients are often recognized at pre-
sentation for elective general surgery procedures. These
patients develop tolerance to opioids, and hyperalgesia
manifests as increased sensitivity to pain and high anal-
gesia requirements compared with those in opioid-
nave patients. Excessive pain increases the risk of both
postoperative pulmonary (owing to splinting and poor
mobilization) and cardiac complications. Patients inad-
equately treated may develop symptoms of nausea,
vomiting, and hemodynamic instability consistent with
narcotic withdrawal.
Grade 1 complication
Axillary nerve block
Supraclavicular nerve block
Interscalene nerve block
Paravertebral nerve block
Lumbar plexus block
Femoral nerve block
Sciatic nerve block
Epidural anesthesia Seizure, arrhythmia, hypotension
Intervention
Opioid dosing remains the mainstay of postoperative
pain control. However, the use of adjuvant therapies,
such as those presented in Table 41, has been shown
to reduce opioid requirements and may aid in treat-
ment of postoperative pain in patients with chronic
pain. Intravenous (IV) narcotics should be used to treat
symptoms of opioid withdrawal.5
Prevention
A patients daily dosage of narcotics as well as expecta-
tions for postoperative pain should be discussed prior
to surgery, and a perioperative pain regimen should be
planned between patient, surgeon, and anesthesiolo-
gist. Standing doses of preoperative pain regimens
should not be stopped pre- or perioperatively. In the
case of gastrointestinal (GI) surgeries, oral medications
should be substituted with IV equivalents after surgery
to prevent withdrawal.5 In addition, patients will require
supplemental narcotics, two to four times the doses
required by opioid-nave patients, for adequate pain
control.6,7 Narcotics can, in part, be effectively admin-
istered by continuous infusion through patient-
controlled analgesia (PCA), which will also provide an
efcient means for delivery of supplemental drugs.5
Adjuvant therapies such as those outlined in Table 41
have been shown to reduce postoperative opioid require-
ments in patients with chronic pain. Of note, epidurals
should utilize lipophilic narcotics because these are more
effective in patients with chronic pain and should not
replace IV narcotics because such management could

Table 42 Commonly Used Narcotics and Their
Approximate Conversion
Drug Oral Dose Intravenous Dose
Hydrocodone 30 mg q3h
Hydromorphone 7.5 mg q3h 1.5 mg q3h
Fentanyl 0.1 mg q1h
Meperidine 300 mg q3h 100 mg q3h
Morphine 30 mg q3h 10 mg q3h
Oxycodone 30 mg q3h
result in withdrawal. Partial opioid agonists such as
buprenorphine or nalbuphine should also be avoided
because they too may cause withdrawal.5
Transition to an oral regimen provides another chal-
lenge for patient and clinician. The equivalent to the daily
postoperative narcotic requirement can be calculated
(Table 42) and prescribed in part (generally one half the
requirement) as long-acting oral opioids such as oxyco-
done or methadone. Intermittent breakthrough doses of
short-acting medications can be prescribed to fulll the
remainder of the daily requirement and can be slowly
tapered to return the patient to his or her baseline narcotic
regimen over a 2- to 4-week period.5
Failure to Recognize Alcohol Dependence
Consequence
Alcohol withdrawal syndrome (characterized by tremor,
insomnia, agitation, hypertension, diaphoresis, fever,
nausea, vomiting, and hallucinations) may precede
delirium tremens (DT) and result in cognitive change,
hallucination, and seizure. Alcohol dependence is
common in surgical patients. Patients with cancers of
the oropharynx and GI tract often have comorbid
alcohol dependence, and more than one third of trauma
patients may be alcohol dependent. Less than one
quarter of these patients are recognized preoperatively
or on admission, resulting in high rates of withdrawal
symptoms and requiring admission to the intensive care
unit (ICU) for hemodynamic and neurologic monitor-
ing as well as aggressive medical intervention.8
Grade 1/4/5 complication
Intervention
Multiple meta-analyses have looked at the treatment
of patients with alcohol withdrawal and DT. Sedative-
hypnotic drugs, generally benzodiazepenes, appear to
be the most effective medications for preventing alcohol
withdrawal seizures and related mortality once symp-
toms of withdrawal occur. The choice of benzodiaz-
epene is based on desired onset and duration of action,
with IV dosing providing the most rapid effect, and
long-acting medications being associated with fewer
breakthrough symptoms but higher rates of overseda-
tion. Intermittent doses of diazepam or lorazepam can
4 PREOPERATIVE PITFALLS 29
Box 41 Sedation Scales
Ramsey Sedation Scale
1 Anxious, agitated, restless
2 Cooperative, oriented, and tranquil
3 Sedated but responds to commands
4 Asleep; brisk response to glabellar tap or loud auditory
stimulus
5 Asleep; sluggish response to light glabellar tap or loud
auditory stimulus
6 Asleep; no response to deep painful stimulus
Richmond Agitation-Sedation Scale (RASS)
+4 Combative Overtly combative or violent,
immediate danger to staff
+3 Very agitated Pulls on or removes tubes or
catheters, aggressive behavior toward
staff
+2 Agitated Frequent nonpurposeful movement
or patient-ventilator dyssynchrony
+1 Restless Anxious or apprehensive but
movements not aggressive or
vigorous
0 Alert and calm
1 Drowsy Not fully alert, sustained (>10 sec)
awakening, eye contact to voice
2 Light sedation Briey (<10 sec) awakens with eye
contact to voice
3 Moderate sedation Any movement (but no eye contact)
to voice
4 Deep sedation No response to voice, any movement
to physical stimulation
5 Unarousable No response to voice or physical
stimulation
Adapted from Ramsey MAE, Savege TM, Simpson BRJ, et al.
Controlled sedation with alphaxalanoe-alphadolone. BMJ 1974;2:656
659; and from Sessler C, Gosnell M, Grap MJ, et al. The Richmond
agitation-sedation scale. Validity and reliability in adult intensive care
patients. Am J Respir Crit Care Med 2002;166:1338.
be repeated until sedation is achieved and then admin-
istered hourly to maintain sedation.9 Affects of benzo-
diazepine and adjuvant medications should be titrated
for light sedation (patient is easily aroused from sleep)
against an objective sedation scale such as the Ramsey
Sedation Score10 or the Richmond Agitation-Sedation
Scale11 (Box 41). Patients can be weaned from treat-
ment medications by titrating for symptoms evaluated
in relation to these tools.
Prescription of clonidine, haldol, or propofol for persis-
tant symptoms can be benecial as an adjunct to benzo-
diazepenes, but these drugs have not been shown to
prevent seizure when given as monotherapy.8,9 Supple-
mentation of IV uids with magnesium, thiamine, and
folate can correct deciencies seen in many patients with
alcohol dependence.
Prevention (Fig. 42)
A thorough history will elicit a history of alcohol use
in many patients with symptoms of liver disease.
 30 SECTION I: GENERAL CONSIDERATIONS

Trauma?

Yes No

Blood alcohol Pre-op evaluation with

level elevated? greater than 3 CAGE
questions answered
affirmatively?
Yes

No Yes
Prophylaxis with
benzodiazepenes to
maintain Ramsey Any CAGE Prophlaxis with
score 24 questions answered benzodiazepenes to
yes or abnormal labs? maintain Ramsey score 24

Yes No

Repeat history and Post-operative symptoms

physical, consider of withdrawal (tachycardia,
post-operative prophylaxis agitation, etc.)?

Yes

Intravenous
benzodiazepenes
with intermittent
doses of these and
adjunct medications
Figure 42 Algorithm for prevention
(clonidine, haldol,
etc) for symptoms and management of alcohol withdrawal in
the surgical patient.

Box 42 CAGE Questions
Have you ever felt you should cut down on your drinking?
Have other people annoyed you by criticizing your
drinking?
Have you ever felt guilty about drinking?
Have you ever taken a drink in the morning to steady your
nerves or get rid of a hangover (eye opener)?
Adapted from Ewing JA. Detecting alcoholism: the CAGE
Questionnaire. JAMA 1984;252:19051907. Copyright 1984,
American Medical Association. All rights reserved.
Laborotory values may be helpful in that elevated liver
function tests and -glutamyltransferase (GGT) may
conrm suspected alcohol use. Alcoholic patients may
be anemic with a high mean corpuscular volume
(MCV). The CAGE questionnaire (Box 42) is com-
monly applied to identify those patients with suspected
alcohol dependence.12 Answering yes to three of the
CAGE questions is strongly correlated with alcohol
dependence, and patients who do so should be placed
on perioperative DT prophylaxis. Afrmative answers
to any of the CAGE questions or laboratory values
suggestive of alcohol dependence should prompt con-
sideration of postoperative prophylaxis, as should an
elevated blood alcohol level measured on admission of
a trauma patient.8
Standard dosing regimens for prophylaxis include
regular administration of diazepam or lorazepam. Again,
haldol and clonidine can be employed for breakthrough
symptoms, and patients should be monitored for signs
of psychomotor agitation, hemodynamic instability, and
cognitive changes.8
Cardiac Risk Assessment and
Preoperative Optimization
Failure to Recognize or Medically Optimize
the Patient with Ischemic Heart Disease or
Congestive Heart Failure
Consequence
Myocardial infarction (MI) and congestive heart failure
(CHF) seen as consequences of subsequent left ven-
tricular dysfunction. Physiologic stress related to oper-
ative procedures and altered rapid eye movement
(REM) sleep secondary to anesthesia are known to be
associated with postoperative MI. In high-risk popula-
tions, rates of postoperative MI have historically
approached 50%. Risk factors for a postoperative cardiac
event were rst described by Goldman and colleagues
in 1977,13 but these have been rened in numerous
studies, as described later.
Grade 1/4/5 complication
Intervention
Treatment for patients with postoperative MI centers
on reduction of oxygen demand and decrease in after-

load. -Blockers reduce heart rate and have been shown
to have a positive effect on mortality after MI. Nitro-
glycerin dilates coronary arteries and improves oxygen
delivery to the myocardium in patients with ongoing
discomfort. This drug also treats CHF and hyperten-
sion. Aspirin is indicated in the setting of acute MI, and
supplemental oxygen should be prescribed. Patients
with ongoing chest pain or hemodynamic instability
should be evaluated for emergent cardiac catheteriza-
tion.14 The risk of bleeding associated with brinolytic
therapy makes this option less feasible in the postsurgi-
cal patient than in the general population of cardiac
patients.
Patients with symptoms of uid overload and CHF may
require ionotropic agents such as dopamine or placement
of an intra-aortic balloon pump. Diuretics are appropriate
for preventing pulmonary edema. These drugs should also
be administered to patients with CHF recognized preop-
eratively and who are experiencing episodes of postopera-
tive decompensation.
Prevention
Patients should undergo a complete preoperative
history and physical examination. Those with cardiac
symptoms or over age 40 require a baseline echocar-
diogram. This evaluation is aimed at identifying factors
Table 43 Preoperative Cardiac Risk Stratication
Adapted from recommendations in Eagle KA, Berger PB, Calkins H, et al. ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation
for Noncardiac Surgeryexecutive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation
2002;105:12571267.
4 PREOPERATIVE PITFALLS 31
contributing to perioperative cardiac risk and was
published in the American College of Cardiology/
American Heart Association Guidelines for Periopera-
tive Cardiac Evaluation for Noncardiac Surgery (Tables
43 and 44). Based on this risk stratication and
the risk of the planned procedure (see Table 43),
indications for further preoperative testing can be easily
identied (see Table 44). With few exceptions, patients
with only minor risk factors can generally undergo
surgery without further testing whereas those with
major risk factors may require preoperative coronary
angiography and medical optimization. Patients at
intermediate risk for surgery have traditionally been
advised to undergo noninvasive testing in the form of
exercise or chemical stress tests to further stratify their
perioperative risk of MI. If reversible perfusion defects
are observed on stress testing, coronary angiography
before intermediate or high-risk procedures is
advisable.15,16
-Blockade has become the mainstay of pharmacother-
apy for prevention of postoperative MI. In randomized,
prospective studies, patients at risk for cardiac events were
given -blockers in the perioperative period and had
reduced incidences of ischemic events and mortality.1719
This has been borne out in a recent meta-analysis.20 When
patients are stratied according to the Revised Cardiac
 32 SECTION I: GENERAL CONSIDERATIONS
Table 44 Preoperative Evaluation for Ischemic Heart Disease
Adapted from recommendations in Eagle KA, Berger PB, Calkins H, et al. ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation
for Noncardiac Surgeryexecutive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation
2002;105:12571267.
Box 43 Revised Cardiac Risk Index (Indications
for Preoperative b-Blockers)
Adapted from Lee TH, Marcantanio ER, Mangione CM, et al.
Derivations and prospective validation of a simple index for
prediction of cardiac risk of major non-cardiac surgery. Circulation
1999;100:10431049.
Risk Index (Box 43), those with three risk factors clearly
benet from preoperative -blockade in conjunction with
high-risk procedures; those with no risk factors do not
require the drug.21,22 Intermediate-risk patients are likely
helped and, in the absence of clear contraindications,
should be prescribed the drugs. In the context of wide-
spread prescription of -blockers, risks of perioperative
cardiac complications have signicantly decreased. In fact,
a contemporary study suggested that preoperative stress
tests may no longer benet patients at intermediate risk
because revascularization does not improve outcomes
after high-risk surgery in certain populations but simply
delays the timing of the procedure.23 In a manner similar
to that of -blockers, recent evaluation of 2-agonists sug-
gests that these medications may prevent perioperative
cardiac events.20
Special attention should be paid to patients with a pre-
operative diagnosis of CHF. These patients should have
a preoperative echocardiogram to delineate function of
the ventricles. Fluid resuscitation should be carefully
monitored and diuretics used to increase urine production
during remobilization (postoperative day 23). Stopping
these medications postoperatively when patients take them
on a regular basis can result in oliguria because renal
function is often dependent on loop diuretics after long-
term use.
Failure to Recognize Risk of Atrial Fibrillation
Consequence
A rapid ventricular response to atrial brillation can
lead to hemodynamic instability; intraventricular clots
can cause thromboembolic events. Risk factors for
development of postoperative atrial brillation include
type of procedure (cardiac and thoracic surgery), prior
history of arrhythmia, and age over 60.
Grade 1/4/5 complication
Intervention
Rate control is known to produce improvement in
blood pressure, allowing for adequate preload. Boluses
of drugs such as calcium channel blockers (e.g., diltia-
zem) or -blockers (e.g., lopressor, esmolol, or labeto-
lol) can rapidly improve rate. These drugs should not
be used in tandem because together they can cause fatal
bradyarrhythmias.
Cardioversion is more often accomplished using antiar-
rhythmics such as amiodorone. Electrical cardioversion
may be necessary in the hemodynamically unstable patient.
No clear difference in long-term outcomes has been
demonstrated between rate control and antiarrhythmic
therapies.24 However, contraindications to the drugs may
dictate therapy. -Blockers are inappropriate in advanced
chronic obstructive pulmonary disease (COPD), and ami-
odorone can cause severe pulmonary toxicity when admin-
istered intravenously after lung resection.25
Additional roles have been identied for drugs such as
adenosine that can slow the heart rate, at least transiently,
to dene the underlying rhythm. Potassium and magne-
sium should be administered to maintain serum levels
greater than 4 mEq/L and 2 mEq/L, respectively, stabi-
lizing myocardial muscle bers. Anticoagulation should be
considered after 48 hours of atrial brillation to reduce
the risk of thromboembolic events.25
Prevention
Recent meta-analyses have examined the role for pre-
operative pharmacologic treatment to reduce rates of

postoperative atrial tachyarrhythmias in cardiac and
thoracic patients. Those patients with risk factors such
as age and requirement for pneumonectomy have been
prescribed preoperative -blockers. This reduces the
incidence of postoperative atrial brillation by more
than one half. Calcium channel blockers have similar
effects in patients undergoing noncardiac thoracic
surgery, and atrial pacing can improve outcomes in
CABG patients. Preventive treatment with magnesium,
amiodarone, or ecanide may prove benecial, but in
this context, the actions of these drugs are incompletely
described.26,27
Pulmonary Risk Assessment and
Preoperative Optimization
Failure to Recognize Obstructive Sleep Apnea
Consequence
Obstructive sleep apnea (OSA) affects 2% to 5% of
the population. It results from failure to protect the
oropharyngeal airway during periods of REM sleep. In
the healthy patient, this results in arousal and resetting
of the respiratory drive. However, the addition of seda-
tion and alterations in sleep rhythm associated with
postoperative pain control and anesthesia can produce
multiple OSA-related complications, including hyper-
tension, MI, and death.28
Grade 1/4/5 complication
Intervention
Initiation of continuous positive airway pressure
(CPAP) should be considered when patients have
observable apnea, although no controlled studies have
proved its efcacy. Treatment of hypertension may
require invasive monitoring and IV antihypertensive
medications including - and -blockers. Arrhythmias
and myocardial ischemia are treated with rate control
and supportive care, as described in prior sections.
Narcotics should be limited and supplemented with
alternative drugs. Benzodiazepenes should be strictly
avoided.
Prevention
As with many preoperative pitfalls, preventing the com-
plications of OSA begins with recognition of the patient
with the disorder. A thorough history and physical
examination should seek to identify those patients with
a known history of OSA and those with witnessed
snoring and apneic episodes at night. A thick neck and
obesity are both associated with OSA. Although sleep
testing (polysomnography) remains the gold stan-
dard for identifying OSA patients, it may not be fea-
sible, owing to lack of access, to preoperatively test all
patients with risk factors.28
Patients with OSA should not be prescribed benzodi-
azepenes because resultant muscle relaxation further com-
promises the airway. Opioids blunt patient response to
4 PREOPERATIVE PITFALLS 33
hypercarbia and hypoxia, resulting in a tendency toward
apnea, and their use should be minimized. Those adjuvant
drugs listed in Table 41 can be used to decrease narcotic
requirements. Continuous pulse oximetry sufces for
monitoring OSA patients in cases in which multiple
comorbidities, high narcotic requirements, or hyperten-
sive volatility are not noted. If these issues are of concern,
ICU monitoring may be warranted in the OSA patient
(Fig. 43).
As noted previously, patients with known or suspected
diagnosis of sleep apnea should be prescribed CPAP in the
pre- and postoperative periods. Patients with observed
episodes of apnea should also be considered for treatment.
No level-one data have shown clear benet with use of
short-term CPAP, although small studies suggest that
patients with OSA on preoperative CPAP may have
better blood pressure control and fewer postoperative
complications.29
Failure to Recognize and Treat Chronic
Pulmonary Disease
Consequence
Postoperative pulmonary complications are common
with prevalences ranging from 6% to 76% based on the
type of procedure and the denition of complications.
Pneumonia, respiratory failure, bronchopleural stula,
atelectasis, and pneumothorax all contribute to postop-
erative morbidity and mortality. American Society of
Anesthesia (ASA) Preoperative Assessment score and
COPD are both major risk factors for the development
of postoperative pulmonary complications. Special
attention should be paid to patients undergoing open
thoracic and upper abdominal surgeries, those receiv-
ing general anesthesia, the elderly, the obese, known
smokers, and the malnourished.30
Grade 15 complication
Intervention
Treatment of postoperative pulmonary complications is
mainly supportive. Pneumonia mandates antibiotic
therapy; chest tube insertion will improve function for
patients with pneumothorax; and mechanical ventilation
can improve oxygenation and acid-base disturbances
in patients with respiratory failure. Respiratory therapy
including bronchodilators and chest therapy can balance
the effects of underlying lung disease and should be
routinely prescribed. Incentive spirometry and CPAP
can be considered as means to increase both forced vital
capacity (FVC) and functional residual capacity (FRC)
in patients with postoperative atelectasis.
Prevention
Adequate patient selection and preparation as well as
preoperative planning have been the primary means
of preventing postoperative pulmonary complications.
In patients undergoing low-risk surgery, history and
 34 SECTION I: GENERAL CONSIDERATIONS
Pre-op diagnosis of sleep apnea?
Yes No
Risk factors for OSA (thick
neck, apneic episodes,
heavy snoring)?
Yes
Pre and post-op Positive Consider sleep
CPAP study.
Post-operative
hypertensive crises,
high narcotic
requirements
Yes No
Consider ICU Continuous pulse
oximetry, minimize
narcotics and
benzodiazepenes.
physical examination can generally identify those at
risk. Complaints of dyspnea or unexplained fevers or a
history of extensive cigarette smoking necessitates
further evaluation by spirometry. In these patients and
those with active pulmonary symptoms, a period of
pulmonary rehabilitation, including intense bronchodi-
lator therapy and respiratory exercises, may improve
surgical outcomes. When possible, incentive spirometry
training should be initiated prior to elective surgery.
Baseline chest radiographs should be documented in
patients of advanced age or with any risk factors for
pulmonary complications.30
Special consideration must be made in patients under-
going thoractomy, esophagectomy, open heart surgery,
and upper abdominal surgeries. Signicant changes in
postoperative lung volumes, pain associated with opera-
tive incisions, and temporary paralysis of the phrenic nerve
contribute to higher rates of postoperative pulmonary
complications. Spirometry is recommended before these
procedures to dene the degree of underlying lung disease
and is essential in patients undergoing pulmonary resec-
tion. A forced expiratory volume measured over 1 second
(FEV1) of greater than 2.0 has traditionally indicated that
a patient is able to undergo pneumonectomy, whereas an
FEV1 greater than 1 to 1.5 L is essential for lobectomy.
In instances in which these volumes are not noted, a
patient may undergo split lung function studies. A post-
operative predictive value of 40% normal is generally
indicative of a candidate with acceptable risk for surgery.
In cases of patients with borderline function, risk stratica-
No
OR
Post-operative apnea
Yes
Consider post-op
CPAP, continuous pulse
oximetry, minimize
narcotics and
benzodiazepenes. Figure 43 Algorithm for
perioperative management of
patients with known or
suspected sleep apnea.
tion can be further dened by exercise tolerance testing30,31
(Fig. 44).
In addition to preoperative pulmonary rehabilitation to
improve lung function, several other options have been
addressed to aid in prevention of pulmonary complications.
Epidural anesthesia has been suggested as a means to
minimize pulmonary complications, although studies differ
on the actual benet associated with this therapy. Laparo-
scopic surgery appears to reduce the postoperative pulmo-
nary risk over those of comparable open procedures though
this may not be a viable option in COPD patients.32
Smoking cessation for greater than 8 weeks preoperatively
decreases pulmonary morbidity, as discussed later.
Screening for Advanced Liver Disease
Failure to Recognize Advanced Liver Disease
Consequence
Surgery in patients with either acute or chronic liver
disease can result in decompensation. Patients are noted
to have worsening coagulopathy with ascites, encepha-
lopathy, hemodynamic instability, and renal failure.
Death can result.
Grade 1/4/5 complication
Intervention
Care of the postoperative patient with liver disease is
supportive. Bleeding must be treated with transfusion
of fresh frozen plasma and platelets to correct elevated
 4 PREOPERATIVE PITFALLS 35

Esophagectomy Lobectomy Pneumonectomy

Cardiac surgery
Abdominal
surgery
FEV1 >1 FEV1 >2L
to 1.5L

Yes No Yes

Pre-operative FEV1 >40% Pre-operative

bronchodilators, predicted on bronchodilators,
pulmonary exercise, split-lung pulmonary exercise,
smoking cessation function studies smoking cessation

Yes No

OR Consider OR
Consider local exercise tolerance Consider local
anesthesia testing versus anesthesia
(vs. general) non-operative (vs. general)
and minimally management and minimally
Figure 44 Algorithm for preoperative pulmonary evaluation in invasive surgical invasive surgical
approaches approaches
patients with lung disease.

prothrombin time and thrombocytopenia, respectively. Table 45 Child-Pugh Class System

Ascites may respond to diuretics. Therapeutic paracen- Assignment of Points
tesis provides temporary relief to patient with restrictive
lung physiology secondary to ascites. Hyponatremia is Points 1 2 3
treated with free water restriction. Encephalopathy Albumin (g/dl) >3.5 2.83.5 <2.8
requires prescription of lactulose with or without enteral
Bilirubin (mg/dl) <2 23 >3
antibiotics such as neomycin. Hemodynamic instability
may require pressor support. Patients with hepatorenal Prothrombin time 13 46 >6
syndrome may be initially treated with uid resuscita- (sec prolonged)
tion, although hemodialysis is eventually required in Encephalopathy None Controlled Dense
many instances.
Ascites None Controlled Refractory
Prevention Calculation of Class (sum points for individual values)
Initial screening for liver disease comprises a thorough
Total Points Childs Class Mortality Rate after Open
history and physical examination. Risk factors for cir- Abdominal Surgery (%)
rhosis including infection with hepatitis B or C, history
of alcohol abuse, or less commonly genetic diseases 56 A 10
such as Wilsons disease and hematochromatosis should 79 B 30
be elucidated. Physical stigmata of cirrhosis include
>9 C 80
spider angiomata, caput medusa, uid wave on abdom-
inal examination, palmar erythema, gynecomastia, and
jaundice. In the case of risk factors or suspected liver
disease, liver function tests (LFTs) and coagulation rection of coagulopathy, treatment of encephalopathy
studies should be ordered. Traditionally, risk stratica- with lactulose) before proceeding to the operating
tion in the cirrhotic patient has been assessed using room.
the Child-Pugh classication33 (Table 45). Although More recently, several small series assessed the role of
patients with class A cirrhosis can generally undergo the model for end-stage liver disease (MELD) score in
surgery with relative few complications, those with preoperative work-up34 (Eq. 1). The MELD score has the
more advanced disease have high rates of complications benet of requiring no objective interpretation by the
and death (see Table 45). Careful weighing of the clinician. MELD score and Child-Pugh class appear to
benets of surgery should be made before counseling correlate well. To date, specic recommendations regard-
the patient, and symptoms of liver disease should be ing risk versus MELD score have been incompletely
controlled by optimal medical management (e.g., cor- dened, although a score greater than 15 appears to
 36 SECTION I: GENERAL CONSIDERATIONS

predict mortality above 15%, MELD greater than 25 pre- Intervention

dicts mortality above 25%, and MELD greater than 35 Treatment of ARF begins with uid resuscitation. A
predicts mortality above 50%.35 central venous pressure of 10 to 12 mm Hg (in the
absence of signicant cardiac dysfunction) can conrm
3.8 ln(bilirubin [mg/dl]) + 11.2 that intravascular volume is sufcient. A Swan-Ganz
(Eq. 1) ln(International Normalized Ratio [INR]) + catheter may be required for more invasive monitoring
9.6 ln(creatinine [mg/dl]) if additional clarication about cardiac contribution to
renal perfusion is needed. Nephrotoxic agents such as
In patients with an acute abdomen and signs of liver those listed in Box 44 should not be prescribed. Sup-
disease, care should be taken to avoid misdiagnosis of portive care with hemodialysis should not be taken
spontaneous bacterial peritonitis (SBP). The physical lightly because uid shifts related to this treatment may
examination in patients with SBP and acute inammatory induce further damage to the kidney. Unremitting
processes can be similar, but exploratory laparotomy runs acidosis, hyperkalemia, or uremia in the context of
the risk of patient decompensation if the true diagnosis renal failure cannot be denitively treated in any other
is SBP. manner, however. Recent studies examined the role of
fenoldopam in preventing progression in patients with
Assessment of Renal Function early ATN. These studies did not show a consistent
improvement in patients receiving the drug, but some
Failure to Recognize Renal Dysfunction
subgroups of patients may benet from its administra-
Consequence tion. Dopamine has no role in the treatment of
Acute renal failure (ARF) may occur in 4% to 8% of ATN.36
critically ill patients in the ICU, and a signicant pro-
portion of these patients will require hemodialysis. The Prevention
most common causes of ARF in postsurgical patients Prevention of ARF begins with recognizing the patient
are prerenal azotemia and acute tubular necrosis (ATN) at risk for ARF (Box 45). Fluid hydration is essential
related to administration of IV contrast or other neph- for those receiving nephrotoxic agents.38 N-Acetyl cys-
rotoxic agents (Box 44). Postrenal causes of ARF are teine can improve outcomes in patients with chronic
often related to malfunction of indwelling catheters renal insufciency (CRI) requiring IV contrast agents.39
and prostatic hypertrophy.36,37 Bicarbonate given in conjunction with IV contrast
Grade 1/4/5 complication agents is believed to act as a scavenger for free radicals
related to these agents and appears to provide some
degree of renal protection.40
Box 44 Commonly Used and Encountered Serum levels of nephrotoxic agents should be routinely
Nephrotoxic Agents measured to prevent supratherapeutic dosing whenever
Iodinated contrast dye
possible (e.g., IV administration of vancomycin, gentami-
Antibiotics cin, and tobramycin). In all other instances, pharmaco-
Vancomycin logic agents should be prescribed after calculation of the
Aminoglycosides patients creatinine clearance as described by Cockroft and
Rifampin Gault41 (Eq. 2). This value is adjusted by a factor of 0.85
Cephalosporins in females.
Penicillins
Amphotericin B
Furosemide
Angiotensin-converting enzyme inhibitors
Box 45 Risks for Acute Renal Failure in the
Angiotensin II receptor antagonists
Surgical Patient
Chemotherapeutics
Cisplatin Surgical procedure
Cyclosporine Cardiac surgery
Tacrolimus Aortic cross-clamping
Allopurinol Liver or renal transplantation
Mitomycin Diabetes/preoperative chronic renal failure
Cocaine Underresuscitation
H2 receptor antagonists Sepsis
Phenytoin Burn injury
Volatile hydrocarbons Liver disease
Myoglobin Cardiac failure
Calcium Ureteral injury
Endotoxin Nonfunctioning indwelling catheter
 4 PREOPERATIVE PITFALLS 37

(Eq. 2) (140 age [in yr]) (weight [in kg]/0.81)
(serum creatinine [in mol/L])
Assessment of Infection Risk and Wound
Healing Ability
Failure to Administer Preoperative Antibiotics
Consequence
Rates of wound infection are related to the type of
procedure and range from 1.5% in clean cases (those in
which there is no associated inammation and no entry
into the alimentary, respiratory, or genitourinary tracts
during surgery) to 40% in dirty cases (those with frank
contamination related to infection or foreign body).
Risk factors for development of wound infection include
the length of procedure (>75th percentile compared
with similar cases), age, diabetes, poor nutritional
status, obesity, and an ASA score of 3, 4, or 5. Immu-
nosuppresive medications including steroids can further
increase rates of poor wound healing and surgical site
infection.42
Grade 15 complication
Intervention
Treatment of surgical infections revolves around drain-
age of abscess collection. This can be accomplished by
opening the skin incision when infections involve the
subcutaneous tissues. Abscess cavities within the surgi-
cal site may require reoperation for drainage or the
placement of a percutaneous drain. Cultures should be
obtained, and antibiotics started empirically at the time
of diagnosis should be tailored based on culture results.
For supercial infections with likely pathogens being
Staphylococcus and Streptococcus, rst-generation cepha-
losporins or penicillin derivatives are adequate coverage
except when methicillin-resistant Staphlyococcus aureus
(MRSA) is suspected, necessitating treatment with
linezolid or vancomycin. For infections related to
pathogens of the respiratory or alimentary tract, com-
bination therapy aimed at anaerobic organisms and
gram-negative bacteria should be employed. Metroni-
dazole with uoroquinolones, piperacillin-tazobactam
combinations, second-generation cephalosporins, and
carbepenams are frequently used combinations.
Prevention
Prevention of wound infection relies on the administra-
tion of preoperative antibiotics (Table 46). Studies
indicate that the proper timing of antibiotic administra-
tion is half an hour before incision, corresponding with
induction of anesthesia. If surgery lasts longer than 2
half-lives of an antibiotic, additional dosing should be
considered. Dilution related to high-volume transfu-
sion should also prompt readministration.42 Although
clean cases were historically not believed to warrant
preoperative antibiotics, this is still debated; benets
have been suggested in numerous studies, especially
in instances in which clean cases involve placement
of a prosthetic mesh as in herniorrhaphy.43,44 Antimi-
crobials acting against staphylococcal and streptococ-
cal species should be administered preoperatively in
these instances. Broader-spectrum drugs or combina-
tion regimens such as those discussed previously are
more appropriate as prophylaxis for surgeries involv-
ing the bowel and the respiratory and genitourinary
tracts.
A signicant decrease in rates of infection after surgery
on the bowel was initially reported when a preoperative
bowel regimen with both mechanical and antimicrobial
preparations was used to decrease the quantity of intralu-
minal bacteria. Although several randomized trials
questioned this practice,45 the standard of care among
surgeons remains mechanical bowel preparation with or
without oral neomycin and erythromycin prior to elective
procedures.46
Incomplete Tobacco Use History
Consequence
Complications related to an incomplete tobacco use
history include poor wound healing, dehiscence, wound

Table 46 Perioperative Wound Infections and Prevention

Rate of Infection (%) Denition Preoperative Antibiotics

Clean 1.5 No inammation First-generation cephalosporin

No entry into GI, GU, or respiratory tract Vancomycin

Clean-contaminated 7.7 Minor break in technique Metronidazole with

Entry into GI, GU, or respiratory tract with no uoroquinolones
spillage Piperacillin-tazobactam
Second-generation cephalosporins
Contaminated 15.2 Major break in technique Carbepenams
Entry into GI, GU, or respiratory tract with spillage
Traumatic wound

Dirty 40 Gross purulence

Fecal contamination
Traumatic wound with delay in treatment

GI, gastrointestinal; GU, genitourinary.

 38 SECTION I: GENERAL CONSIDERATIONS

infection, pneumonia, failed vascular reconstruction, Patient with pre-operative

increased ventilator dependence, anastomotic leaks, weight loss or albumin 2.5
and death.47
Grade 15 complication
Intervention
Treatment of smoking-related complications is mainly
supportive. Aggressive pulmonary toilet including
Enteral supplementation
incentive spirometry, early ambulation, and suctioning failed?
may aid in recovery from pneumonia and improve
respiratory function. Wound infections should be Yes No
treated with antibiotics and drainage and dehiscence
with operative repair.
One week parenteral
Prevention nutrition for
supplementation
Although aggressive pulmonary toilet may help to
prevent pneumonia and respiratory failure in smokers
postoperatively, an overall reduction in surgery-related OR
Consider placement of enteral
complications may be improved by smoking cessation feeding tube if anticipate
before surgery.47 An 8-week window is believed to persistant failure to feed orally
improve pulmonary function and decrease pulmonary or anticipate prolonged post-
operative fast.
secretions that predispose patients to pneumonia and
COPD exacerbation.48 Recent studies suggest that
patients who enter a preoperative smoking-cessation
program may reduce rates of wound as well as pulmo-
nary complications. These reports vary in their degree Pre-operative TPN?
of signicance, and no clear duration of abstinence has
No Yes
been dened to be required for observations of these
benets.49,50
Failed enteral feeding Continue parenteral
anticipated to continue supplementation until
Assessment of Nutritional Status to two weeks? enteral feedings adequate
to meeting nutritional
Failure to Assess Patient Nutritional Status requirements
Yes
Many patients referred for surgery have chronic GI dys-
function or anorexia related to cytokine production and
associated with malignancy. Severely malnourished patients Initiate TPN
are generally dened as those with albumin levels less than
Figure 45 Management of the malnourished surgical patient.
2.5 g/dl and those with preoperative weight loss greater
than 20%.51
Intervention
Consequence A protocol for identifying and treating the malnour-
Common consequences of failure to assess a patients ished surgical patient is presented in Figure 45. History
nutritional status include dehiscence of the surgical or laboratory values consistent with severe malnutrition
wound and anastomotic breakdown. Wound healing is are an indication for preoperative TPN. Calculation of
more signicantly compromised in those defects that nitrogen balance, as described in Eqs. 3, 4, and 5, can
are not treated by primary reanastomosis, but instead conrm whether a patient is catabolic (negative balance)
heal by secondary intention. Infection may progress to or anabolic (positive balance).
multiple organ system failure (MOSF) and death.52
Grade 15 complication (Eq. 3) Nitrogenin = protein (in g/day)/6.25
(Eq. 4) Nitrogenout = urinary nitrogen (in g/day) +
Repair
insensible losses (28 g/day)
Repair is directed toward treatment of associated
complications. Wound dehiscence requires reopera- (Eq. 5) Nitrogen balance = nitrogenin nitrogenout
tion. Anastomotic breakdown dictates prolonged
fasting with total parenteral nutrition (TPN) for nutri- The Veterans Administration Total Parenteral Nutrition
tional support. Antibiotics should be prescribed for Cooperation study53 stratied patients according to degree
associated infections and ICU support prescribed for of malnutrition as evidenced by preoperative weight loss
MOSF. and hypoalbuminemia and randomized patients to treat-

ment with preoperative TPN or to a control group. In
severely malnourished patients, the risk of noninfectious
complications (e.g., anastomotic leaks, bronchopleural s-
tulae, MOSF) with a 7-day course of preoperative TPN
was reduced from 43% to 5%. Increased rates of infectious
complications did not appear to justify the use of TPN in
mild to moderately malnourished populations, however.
These ndings have been borne out by multiple subse-
quent trials and have resulted in the adoption of preop-
erative TPN as the standard of care in severely malnourished
patients. Treatment appears to be of no benet when
prescribed for less than 1 week.
Postoperatively, patients should continue TPN started
preoperatively until enteral feeds can be initiated. The
question of postoperative TPN in patients without indica-
tions for preoperative therapy was addressed by a random-
ized study published by Sandstrom and associates,54 which
noted increased rates of postoperative complications in
those patients unable to tolerate oral feeds after GI surgery
and receiving only IV uids for longer than 14 days. In
patients without contraindications, early enteral feedings
(administered as early as 6 hours postoperatively in some
series of esophagectomy patients) are clearly superior to
postoperative TPN, reducing rates of postoperative infec-
tious complications and length of ICU and hospital
stays.55,56 No clear evidence relating mortality to mode of
feeding has been published.
Assessment of Bleeding Risk and Identication
of the Hypercoagulable Patient
Failure to Identify the Patient at Risk of Bleeding
Consequence
Inherited and acquired coagulopathies place patients
at risk for surgical bleeding. Special attention should
also be placed on the signicant proportion of older
surgical patients who are maintained on antiplatelet
and anticoagulant medications for treatment and pre-
vention of cardiovascular conditions. End-stage renal
disease (ESRD) and liver disease (ESLD) are comorbid
conditions associated with signicant risk of bleeding
diathesis.
Grade 15 complication
Intervention
Platelet dysfunction as seen in renal disease can
be treated with 1-deamino(8-D-arginine) vasopressin
(DDAVP) and platelet transfusion should excessive
bleeding occur. Transfusion of platelets alone should
be used for treatment of thrombocytopenia and con-
sumptive coagulopathies and in patients receiving
massive transfusion of packed red blood cells. Fresh
frozen plasma can be used for treatment of bleeding
associated with deciency of most factors in the clot-
ting cascade, and transfusion with concentrated recom-
binant factors can be used for von Willebrand disease,
as well as for factor VIII and IX deciencies. Local
4 PREOPERATIVE PITFALLS 39
control can be achieved with brin sealants or collagen-
enriched matrices. Activated factor VII can be admin-
istered in patients with ongoing bleeding in whom
standard transfusion therapies have failed to improve
the clinical condition.57
Prevention
Coagulation disorders can be elucidated on history by
inquiring about previous episodes of unusual bleeding.
Recurrent GI bleeding, epistaxis, hematuria, menor-
rhagia, or hemarthroses suggest a bleeding disorder.
History of ESRD is associated with platelet dysfunc-
tion, and stigmata of ESLD are worrying for coagu-
lopathy and thrombocytopenia. Collagen vascular
diseases including lupus and Ehlers-Danlos are risks for
intraoperative bleeding. Poor diet is associated with
vitamin K deciency and decits in clotting factors.
Organomegaly warrants further work-up to rule out
liver or hematologic disorders.58 In the absence of any
of the previously cited risk factors, no evidence has
been found to indicate that further work-up is neces-
sary before elective surgery to exclude bleeding disor-
ders. In fact, in a population of low-risk patients, the
partial thromboplastin time (PTT) was found to have
no predictive value as related to postoperative hemor-
rhage.59 Preoperative preparation with known coagula-
tion defects are described in Table 47.60
Patients on oral anticoagulation or antiplatelet regimens
require special care. Recovery of adequate platelet func-
tion requires at least 2 to 4 days after stopping aspirin.
Similar results affect management of patients on clopido-
grel and ticlopidine, irreversible inhibitors of platelet func-
tion. Complete recovery of platelet function takes 7 days,
and patients should be instructed to cease taking antiplate-
let agents 5 to 7 days before elective surgery. If the risk
of acute thrombus is high as in patients with recently
placed coronary artery stents, elective surgery should
be postponed. Emergent surgery can be performed on
patients taking aspirin or novel antiplatelet drugs because
postoperative bleeding risk is generally limited to wound
hematoma. More severe bleeding risk is present, however,
when patients are on both aspirin and clopidogrel because
these drugs act synergistically and perioperative morbidity
is great in this population.61
Management of coumadin in the perioperative setting
is based on the indication for which it is prescribed
(Fig. 46). The complications of thromboembolic events
require perioperative bridging with unfractionated heparin
or low-molecular-weight heparin in patients with mechan-
ical heart valves. Recent venous embolic disease (within
1 mo) similarly indicates the need for perioperative heparin
derivatives.6264
Failure to Treat for Hypercoagulable State
Consequence
The incidence of deep venous thrombosis (DVT) was
historically quoted as ranging from 15% to 30% in
 40 SECTION I: GENERAL CONSIDERATIONS

Table 47 Treatment of Coagulation Factor Disorders

Bleeding Disorder Target Factor Level Plasma Product

Hemophilia A

Minor surgery >30% for 34 days

Major surgery >80%100% for 4 days, then >50% for 37 days Recombinant or plasma-derived
monoclonal factor VIII concentrates

Cardiovascular, prostate, and neurosurgery >100% for 3 days, then 80%100% for 710 days

Hemophilia B

Minor surgery >30% for 34 days

Major surgery >80%100% for 4 days, then >50% for 37 days Recombinant or monoclonal plasma-
derived factor IX concentrates

Cardiovascular, prostate, and neurosurgery >100% for 3 days, then 80%100% for 710 days

von Willebrand Disease

Minor surgery >50% for 13 days DDAVP or vWF-containing factor VIII

concentrates

Major surgery Keep 50%100% for 710 days

Factor XI Deciency

Minor surgery >30% for 34 days FFP

Major surgery >45% for 710 days

Factor VII Deciency

Minor surgery >15% FFP or recombinant human factor VIIa

Major surgery >25%

Factor X Deciency

Minor surgery >15% FFP or prothrombin complex concentrates

Major surgery >50% perioperatively, then >30%

Factor V Deciency

Minor surgery >25%

Major surgery >50% perioperatively, then >25% FFP

Prothrombin Deciency

Minor surgery 20%40% FFP or prothrombin complex concentrates

Major surgery 20%40%

A- or Hypobrinogenemia

Minor surgery >50100 mg/dl for 13 days Cryoprecipitate

Major surgery >50100 mg/dl for 23 wk

Factor XIII Deciency

Minor surgery >5% FFP or cryoprecipitate

Major surgery >5%

DDAVP, 1-Desamino-8-D-arginine vasopressin; FFP, fresh frozen plasma; vWF, von Willebrand factor.
From Streiff MB. Abnormal operative and postoperative bleeding. In Cameron J (ed): Current Surgical Therapy, 8th ed. Philadelphia: Elsevier Mosby,
2001; p 1124, Table 4.
 4 PREOPERATIVE PITFALLS 41

Stop coumadin 4 days pre-operative

Low risk for Intermediate risk High risk (mechanical valve,

thromboembolism (atrial DVT within 1 month)
fibrillation or DVT 3
months before procedure)

Admit for Therapeutic

therapeuticic LMWH starting
heparin 2 days 2 days
Post-operative DVT Prophylactic heparin pre-operatively pre-operatively
prophylaxis with or LMWH starting two
LMWH or heparin days pre-operatively,
continuing post-
operatively
D/C 46 hours D/C 12 hours pre-
pre-operatively operatively and
Restart coumadin Resume coumadin and restart 12 restart 12 hours
on POD 0 on POD 0 hours post-op post-op

Figure 46 Perioperative manage- Resume coumadin on

ment of the patient on coumadin. POD 0, stop heparin or
LMWH, low molecular weight LMWH after therapeutic INR
heparin.

postsurgical patients before the institution of prophy-
lactic measures. Pulmonary embolism caused death in
0.2% to 0.9% of patients.65,66 In fact, as many as 29%
of postoperative deaths occurring in the rst 30 days
after a procedure and in prophylaxis may have resulted
from pulmonary embolism (PE) according to some
autopsy studies.67
Grade 1/4/5 complication
Intervention
Although surveillance for postoperative DVT is rarely
indicated, symptoms of unilateral lower extremity pain,
color change, or edema should prompt emergent
imaging, duplex ultrasonography (DUS), of the deep
veins. In cases in which a high clinical suspicion for
DVT is present, yet DUS is negative, pelvic computed
tomography (CT) or venography may be useful to
delineate the presence of a pelvic clot. Unexplained
respiratory distress and an elevated arterial-alveolar gra-
dient requires spiral CT scan of the chest, ventilation-
perfusion (V/Q) scanning, or pulmonary angiography
to rule out PE.
After diagnosis of a DVT or PE, patients should be
immediately started on therapeutic anticoagulation. A
high index of suspicion and respiratory distress is indi-
cated for empirical treatment. High-dose unfractionated
heparin should be administered intravenously to obtain an
activated PTT between 60 and 80 seconds. Recently, low-
molecular-weight heparins such as enoxaparin have been
employed, and this drug, given subcutaneously in doses
of 1 mg/kg twice daily (once daily in renal failure patients),
has been shown to be equally effective in preventing clin-
ical sequelae of DVT and PE.68 In the case of severely
compromised oxygenation ability, thrombolysis may be
essential, but the risk of postoperative bleeding should be
recognized.
In patients at risk for bleeding and who have a contra-
indication to anticoagulation, or in those who develop
DVT or PE despite medical therapy, an inferior vena cava
(IVC) lter can be placed in the setting of DVT to prevent
migration of the clot to the lungs.69 Long-term conse-
quences of DVT including venous stasis are not addressed
by this mode of therapy; however, and multiple complica-
tions are associated with IVC lter placement including
recurrent DVT, lter migration, insertion site injury, and
IVC occlusion. Recently, removable IVC lters have been
approved for use in the U.S. market, aiming to prevent
these complications by lter retrieval after the risk of PE
decreases.70 Results related to these lters are incompletely
characterized. They do appear to prevent PE, but almost
50% are unable to be removed owing to ongoing contra-
indications to anticoagulation or to large emboli wedged
in the lter.71
Prevention
Surgery itself is a risk factor for development of DVT
and PE, but as in the prevention of most postoperative
complications, a thorough history and physical exami-
nation should be completed to assess a patients risk for
coagulation disorders. The conditions most commonly
associated with elevated risk of postoperative DVT and
PE are age, obesity, previous DVT or PE, genetic
predisposition, and cancer.70 It should be noted that
orthopedic procedures (major joint surgery) and
 42 SECTION I: GENERAL CONSIDERATIONS
Table 48 Thromboembolism Risk in Surgical Patients
DVT (%)
Level of Risk Calf
Low risk 2 0.4
Minor surgery in patients <40 yr with no additional
risk factors
Moderate risk 1020
Minor surgery in patients with additional risk factors
Surgery in patients aged 4060 yr with no additional
risk factors
High risk 2040
Surgery in patients >60 yr, or age 4060 with
additional risk factors (prior VTE, cancer,
molecular hypercoagulability)
Highest risk 4080
Surgery in patients with multiple risk factors (age
>40 yr, cancer, prior VTE)
Hip or knee arthroplasty, HFS Major trauma; SCI
GCS, glucocorticosteroid; INR, International Normalized Ratio; IPC, intermittant pneumatic compression; LDUH, low dose unfractionated heparin;
LMWH, low-molecular-weight heparin; SCI, spinal cord injury; VKAs, vitamin K antagonists; VTE, venous thromboembolism.
From Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolismthe Seventh ACCP Conference on Antithrombotic and
Thrombolytic Therapy. Chest 2004;126(suppl):338400, Table 5.
therapy for trauma carry high risks of venous thrombo-
embolic disease (VTED). Risks after colorectal surgery
are somewhat higher than those following other general
surgery procedures.
Recommendations for prevention of postoperative
VTED are based on a consensus statement by the
American College of Chest Physicians Conference on
Antithrombotic and Thrombolytic Therapy.72 Prescrip-
tion of postoperative graded compression stockings,
low-dose unfractionated heparin, low-molecular-weight
heparin, or vitamin K inhibitors (e.g., coumadin) is based
on the type of surgery the patient has undergone and the
number of risk factors a patient is known to have. Table
48 summarizes these recommendations, which are based
on currently available randomized, controlled trials and
meta-analyses.72
The role of IVC lters in the prevention of PE in surgi-
cal patients is poorly dened. Although clinicians have
resisted this indication in an attempt to prevent long-term
complications of the lters, the possibility of removable
lters has encouraged reexamination of this therapy.
Obesity and trauma surgery are the rst elds likely to
adopt routine prophylactic IVC lter placement owing to
the high rate of VTED in respective patient populations.70
Patients with known DVT and surgical disease are also
considered for prophylactic IVC lter placement.
Identication of Endocrine Dysfunction
Failure to Treat and Prevent Hyperglycemia
Consequence
Multiple studies have demonstrated that patients with
poor blood sugar control have higher rates of wound
PE (%)
Proximal Clinical Fatal Successful Prevention Strategies
0.2 <0.01 No specic prophylaxis; early and
aggressive mobilization
24 12 0.10.4 LDUH (q12h), LMWH (3400 U
daily), GCS, or IPC
48 24 0.41.0 LDUH (q8h), LMWH (>3400 U
daily), or IPC
1020 410 0.25 LMWH (>3400 U daily),
fondaparinux, oral VKAs (INR, 2
3), or IPC/GCS + LDUH/LMWH
infections.7375 ICU patients with hyperglycemia are
prone to septicemia and resultant MSOF.76 Complica-
tions of diabetes such as gastroparesis and neuropathy
place patients at risk of aspiration and autonomic insta-
bility, respectively, and indicate that both anesthesio-
logists and surgeons must be aware not only of the
immediate effect of hyperglycemia on postoperative
healing but also of the derangements associated with
chronic physiologic changes related to diabetes.77,78
Grade 1/4/5 complication
Intervention
In patients with persistent hyperglycemia, aggressive
control to maintain blood sugar below 120, as discussed
later, is essential. Treatment of infections is mainly
supportive, with IV antibiotics tailored to the microor-
ganism, dbridement or drainage as necessary, and ven-
tilatory or dialysis support as required for MSOF.
Prevention
Preventing the postoperative complications related to
diabetes begins before the induction of anesthesia (Box
46). Patients should be directed to stop taking oral
antihyperglycemics the day before surgery to prevent
interactions with anesthesia that may result in lactic
acidosis and arrhythmia. Long-acting insulin medica-
tions should be taken through the day of surgery, but
after initiation of the fast, injection with short-acting
analogues should stop to prevent hypoglycemic reac-
tions. The fast should be broken before the start of
surgery by administration of IV dextrose. This appears
to minimize the insulin resistance observed postopera-
tively. When possible, epidural anesthesia should be

Box 46 Perioperative Management of Diabetes
Hold short-acting insulin and oral medications with onset
of fast.
Continue long-acting insulin analogues (L-glargine) on day of
surgery
Break fast immediately preoperatively with dextrose-
containing IV uid
Low threshold for insulin drip intra- and postoperatively
Floor patients with goal blood sugar <150
Intensive care unit patients with goal blood sugar <120
considered because this blunts the physiologic stress
response related to surgery and the related insulin resis-
tance and hyperglycemia. Nasogastric tubes should
be inserted liberally, and erythromycin should be con-
sidered to prevent aspiration related to poor gastric
motility.
The benet of tight blood glucose control using insulin
has recently been shown via a large randomized, con-
trolled study of ICU patients treated with IV insulin infu-
sion to maintain blood glucose levels of 80 to 110 versus
180 to 200. A signicant proportion of the patients in this
study were surgical patients. Tight control was related to
a decrease in mortality from 8% to 4.6%. Decreased
requirements for ventilatory support and renal replace-
ment therapy were observed in the aggressively treated
patient population, and rates of septicemia were reduced
from 67% to 25%.76 Although it remains to be dened
whether blood sugars must be maintained as low as the
aggressively treated group in this study, it is obvious that
hyperglycemia must be constantly evaluated and treated.
Failure to Recognize Adrenal Insufciency
Consequence
Hypotension and shock are consequences of failure
to recognize adrenal insufciency. Glucocorticoids
perpetuate the actions of catecholamines, supporting
blood pressure and potentiating their ionotropic effects.
Postoperative patients with unrecognized adrenal insuf-
ciency may initially complain of abdominal pain with
nausea, vomiting, and diarrhea and progress to a shock
state requiring vasopressors for blood pressure support.
In primary adrenal insufciency (diseases affecting the
adrenal gland itself and not regulation via pituitary or
hypothalamic regulatory pathways), mineralocorticoid
decits may manifest as persistent hyponatremia and
hyperkalemia.
Grade 1 complication
Intervention
Stress dose steroids can improve hemodynamic stabil-
ity, allowing patients to wean from pressor support.
Prevention
The most common form of adrenal insufciency
encountered by the surgeon is tertiary adrenal insuf-
4 PREOPERATIVE PITFALLS 43
ciency, which is seen in patients treated with steroids
for comorbid conditions such as inammatory bowel
disease, COPD, collagen vascular diseases, rheumatoid
arthritis, or central nervous system tumors. Patients
receiving more than 5 days of methylprednisolone
dosed at 20 mg or greater each day are likely to have
suppression of the adrenal axis.79 The adrenal axis does
not fully recover for over 9 months, suggesting that
anyone who has received high-dose steroids during the
year before surgery should be evaluated for adrenal
insufciency.80 Low-dose steroids (5 mg daily of meth-
ylprednisolone or its equivalent) do not generally result
in adrenal insufciency, and these patients should not
require stress doses of steroids preoperatively.81
Patients with a history or risk factors for tuberculosis,
advanced human immunodeciency syndrome, or auto-
immune diseases should be screened with laboratory
testing for signs of primary adrenal insufciency. Physical
signs include hyperpigmentation, chronic fatigue, weight
loss, diarrhea, abdominal pain, and emesis. Hyponatremia
or hyperkalemia may be present, representing mineralo-
corticoid deciencies. Patients using chronic topical or
inhaled steroids may develop tertiary adrenal insufciency.
Pituitary tumors may compromise the production of adre-
nocorticotropic hormone (ACTH), resulting in secondary
adrenal insufciency.82
If risk factors for adrenal insufciency are identied,
patients without a clear need for steroids can be evaluated
using a corsyntropin stimulatory test, which evaluates the
effect of exogenous stimulation on cortisol production.
Failure to respond adequately denes a subset of patients
who will require stress dose steroids. Dosing of stress dose
steroids and requirement for postoperative tapering are
based on the extent of the surgical procedure.81
Special note should be made of the risk for poor wound
healing in patients on chronic steroids. This is related to
increased risk of wound dehiscence, anastomotic leak, and
stump breakdown. High doses of vitamin A and vitamin
C can potentially improve outcomes, and reinforcement
of the surgical site with retention sutures or tissue aps
should be considered when tissues are noted to be friable
and weak.
Documentation of the Family History
Failure to Take an Adequate Family History
Consequence
Metachronous cancers, missed synchronous cancers,
and recurrent vascular disease are consequences of
failure to take an adequate family history. The advent
of genetic testing and the description of familial cancer
syndromes have resulted in a need for carefully consid-
ering a patients family and personal medical histories
to identify those with cancer syndromes and those
with advanced vascular disease owing to metabolic
aberrations.
Grade 15 complication
 44 SECTION I: GENERAL CONSIDERATIONS

Table 49 Genetic Syndromes Commonly Encountered by the Surgeon

Syndrome Genetic Defect Associated Cancers Diagnosis Treatment and Screening

FAP APC Colorectal cancer in 4th decade
Duodenal adenocarcinoma
Rarely pancreatic, biliary, ileal
pouch adenoma, gastric
adenoma, papillary thyroid
cancer, hepatoblastoma
Family history Colonoscopy beginning between ages
Endoscopic identication 10 and 20
of 100s to 1000s of Upper tract endoscopy every 25 yr
colorectal polyps Annual physical examination for
Genetic testing thyroid nodules
Consider AFP and abdominal US until
age 6 yr to identify hepatoblastoma
Prophylactic colectomy in 2nd decade

Attenuated APC Right-sided polyps more As in FAP Prophylactic colectomy vs.

FAP common endoscopic polypectomies
Variable incidence of colon EGD, thyroid, and hepatoblastoma
cancer screening as in FAP

Gardner APC Variable incidence of colon As in FAP As noted earlier in attenuated FAP
syndrome cancer
Osteosarcoma, lipoma,
sebaceous cyst neoplasms,
dental abnormalities

Turcot APC or Variable incidence of colon As in FAP As noted earlier in attenuated FAP
syndrome microsatellite cancer
instability Medulloblastoma and
glioblastoma multiforme

HNPCC hmL1, hmSH2, Early-onset colon cancer Amsterdam criteria for Colonoscopy starting 10 yr before
(Lynch 1) hmsH6, PMS2 Right-sided colorectal cancer diagnosis the earliest colorectal cancer in the
(microsatellite Histology signicant for Three affected family pedigree
instability) microsatellite instability, signet members Local resection with annual to
ring cells, mucinous neoplasms, One is the rst-degree biennial colonoscopy or subtotal
lymphocytic inltrate relative of the other two colectomy
Metachronous cancers One is diagnosed before Annual urinalysis and urine cytology
Endometrial cancer age 50 Annual endometrial aspiration biopsy
Small bowel cancer Disease affects two or transvaginal ultrasound; consider
Transitional cell carcinoma successive generations postmenopausal hysterectomy
Caf-au-lait spots Genetic testing Gastroscopy in families with affected
Gastric cancer in certain pedigree
pedigrees

Peutz-Jeghers STK 11 (LKB 1), Mucocutaneous Family history Biennial EGD and upper GI with small
a serine- hyperpigmentation Histologic examination of bowel follow-through starting at age
threonine kinase Intestinal hamartomas small intestine hamartomas 10
Gastrointestinal cancers Mucocutaneous Biannual colonoscopy starting in early
Rarer breast, endometrial, hyperpigmentation adulthood
pancreatic, lung, cervical, Genetic testing
testicular cancers

JPS PTEN, SMAD4, Colorectal cancer Family history with JPS Annual colonoscopy with
BMPR1A Digital clubbing polyps polypectomy starting in teens
Gastric polyposis and cancer >5 juvenile polyps with Biennial EGD
conrmed histology Consider prophylactic subtotal
JPS polyps throughout colectomy
intestinal tract

Cowden PTEN As in JPS As in JPS with additional As noted earlier in JPS

disease Breast cancer characteristics noted in Mammography starting at age 30
Thyroid cancer previous column Thyroid screening beginning in teens
Multinodular goiter Difcult to distinguish
Facial tricholemmas from JPS and may be
subset
 4 PREOPERATIVE PITFALLS 45

Table 49 Genetic Syndromes Commonly Encountered by the Surgeoncontd

Syndrome Genetic Defect Associated Cancers Diagnosis Treatment and Screening

BRCA BRCA Breast Family history Breast conserving therapy vs.

mutation Ovarian (premenopausal breast mastectomy (therapeutic or
carrier Colon cancer, male breast cancer, prophylactic)
Prostate ovarian cancer, multiple Annual mammogram, consider
Pancreatic affected members of alternating every 6 mo with annual
family) MRI
Genetic testing of affected Consider postmenopausal bilateral
individuals if possible, salpingoopherectomy
otherwise related Tamoxifen for 5 yr
members Consider aromastat inhibitors after
tamoxifen course

MEN 1 Menin Parathyroid hyperplasia
Pancreatic neoplasms
(predominantly neuroendocrine)
Anterior pituitary gland
neoplasms
Rarely lipoma, adrenal/thyroid
adenomas, cutaneous
angiobromas, bronchial/thymic
carcinoids
Family history Annual screening for hormones
Genetic testing related to functioning neuroendocrine
tumors of the pancreas
Consider additional work-up with
CT, somatostatin-receptor
scintography, MRI for symptoms
Annual calcium, PTH, screen for
symptoms of prolactinoma,
acromegaly

MEN 2 Ret Medullary thyroid cancer Family history Prophylactic thyroidectomy

Pheochromocytoma Genetic testing Screening for symptoms of
Mucosal neuromas (MEN 2B pheochromocytoma by history and
only) measurement of urinary
Neurobromatosis (MEN 2B catecholamines, serum metanephrines
only) Resect pheochromocytoma before
Marfanoid habitus (MEN 2B thyroid cancer
only) Unilateral (consider bilateral)
Hyperparathyroid (MEN 2A adrenalectomy for
only) pheochromocytoma

AFP, -fetoprotein; CT, computed tomography; EGD, esophagogastroduodenoscopy; FAP, familial adenomatous polyposis; GI, gastrointestinal;
HNPCC, hereditary nonpolyposis colorectal cancer; JPS, juvenile polyposis syndrome; MEN, multiple endocrine neoplasia; MRI, magnetic resonance
imaging; PTH, parathyroid hormone; US, ultrasound.

Intervention
Patients will require additional surgeries or develop
progressive disease.
Prevention
Hyperhomocystinemia is an important consideration in
the vasculopath. These patients develop early-onset
cardiac and peripheral vascular symptoms, a history
often seen in other family members as well. Treatment
with vitamin supplementation may blunt progression
of atherosclerotic changes.
Cancers that develop in the context of germline
mutations require special cancer screening protocols,
preoperative planning, and extensive discussion with
patients regarding genetic testing of themselves and their
families. Table 49 summarizes the best characterized
of these syndromes and protocols, their recognition, diag-
nosis, and appropriate treatment strategies for these
patients.8389
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 46 SECTION I: GENERAL CONSIDERATIONS
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 48 SECTION I: GENERAL CONSIDERATIONS
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5
Anesthesia for the Surgeon
Ankur Gosalia, MD and Babak Sarani, MD
INTRODUCTION
Perioperative management has changed signicantly since
the early 1980s. Specically, many operations that his-
torically required preoperative hospitalization are now
performed as same-day admission, outpatient, or ofce-
based procedures. An estimated 400,000 outpatient surgi-
cal procedures were performed in 1984, compared with
8.3 million procedures in 2000.1 Because of this, surgeons
must be familiar with anesthesia techniques, risks, and
pitfalls.
Persons older than age 65 make up the fastest-growing
segment of the population in the United States and are
expected to account for 20% of the population by 2025.2
As expected, this segment of the population has many
comorbidites that must be accounted for when evaluating
perioperative risk and the safety of outpatient procedures
requiring conscious sedation. Familiarity with methods
used to assess operative risk can make preoperative evalu-
ation and preparation smooth and cost effective.
Utilizing an organ systembased approach, this chapter
discusses anesthetic pitfalls with which the surgeon should
be familiar. The chapter is further divided into issues
related to surgery in the outpatient/ofce-based setting
and those related to more invasive inpatient procedures.
For the latter, an organ systembased discussion is used
to discuss pitfalls in the preoperative, intraoperative, and
postoperative settings.
OUTPATIENT AND OFFICE-BASED
ANESTHETIC PITFALLS
Neurologic System
Tables 51 and 52 list many of the commonly used
analgesic and amnestic/anxiolytic agents, their doses, and
reversal agents.
Meperidine-Related Seizure
Meperidine (Demerol) has a unique prole in that it has
a toxic metabolite, normeperidine, that has a longer half-
life than the parent drug but no analgesic effects. Norme-
peridine can accumulate to toxic levels in patients with
hepatic or renal dysfunction.
Consequence
Persistent dosing of meperidine can cause accumula-
tion of normeperidine to toxic levels that can lead to
life-threatening seizures. These seizures are extremely
difcult to control.
Grade 4/5 complication
Repair
Seizures related to the use of meperidine should be
treated immediately with benzodiazepines (preferably
midazolam [Versed] or lorazepam [Ativan]). Sodium
thiopental or propofol can also be used, but these
agents are more likely to cause severe hypotension.
Phenytoin (Dilantin) is not effective in stopping or
preventing seizures due to normeperidine. Patients may
require intubation to control the airway if the seizures
do not stop.
Prevention
The use of meperidine for analgesia should be avoided
entirely or minimized in all patients because this agent
does not have a favorable analgesic prole in compari-
son with morphine, hydromorphone (Dilaudid), or
fentanyl and has the potential to cause seizures in those
patients with renal and hepatic impairment. If meperi-
dine must be used, only small, incremental doses should
be administered, especially in the outpatient setting.
This agent is contraindicated in those with signicant
renal or hepatic dysfunction.
Local AnestheticRelated Seizure
Consequence
Intravascular administration of local anesthetic or over-
dose into the interstitium can cause life-threatening
seizures.3 Bier blocks are whole extremity blocks per-
formed by intravenous injection of high doses of local
anesthetic in an extremity that has been isolated via a
tourniquet. Such blocks can cause seizures if the tour-
niquet is released before the injected anesthetic has
dissipated to nontoxic levels or is not sufciently tight
to prevent systemic exposure. Table 53 lists the com-
monly used local anesthetics, doses, and duration of
effect.
Grade 4/5 complication
 50 SECTION I: GENERAL CONSIDERATIONS

Table 51 Commonly Used Analgesics

Agent Dose Duration Pitfalls and Side Effects

Morphine 0.020.08 mg/kg IV (26 mg IV) 26 hr Respiratory depression,* hypotension,* itching

Meperidine (Demerol) 0.20.75 mg/kg IV (2550 mg IV) 24 hr Seizure, respiratory depression*

Fentanyl 0.51 mcg/kg IV (25100 mcg IV) 30 min1 hr Respiratory depression,* depot effect when used chronically

Hydromorphone (Dilaudid) 0.0010.02 mg/kg IV (0.12 mg IV) 26 hr Respiratory depression*

Ketorolac (Toradol) 1530 mg IV or PO 46 hr Nephrotoxic, ulcerogenic, platelet dysfunction

Naloxone 40400 mcg 510 min Seizure, acute pain

Ketamine 0.51 mg/kg IV 30 min Hallucination

*Dose dependent.

Not recommended for chronic pain owing to accumulation of toxic metabolite.

Use with extreme caution in patients with renal or liver insufciency.

Continuous or frequent dosing can cause signicant build-up in fat stores owing to lipophilic prole.

Limit continuous intravenous dosing to 46 days.

Reversal agent for all opioids. Can induce withdrawal if administered quickly.
IV, intravenously; PO, orally.
From Rutter T, Tremper K. Anesthesiology and pain management. In Greeneld L, Mulholland M, Oldham K, et al (eds): Surgery: Scientic
Principles and Practice, 2nd ed. Philadelphia: Lippincott-Raven, 1997; pp 438454.

Table 52 Commonly Used Amnestic/Anxiolytic Agents

Agent Dose Duration Time to Onset (min) Pitfalls and Side Effects

Midazolam (Versed) 24 mg IV 30 min 1 min Respiratory depression, hypotension*

Lorazepam (Ativan) 24 mg IV 46 hr 5 min Respiratory depression, hypotension*

Diazepam (Valium) 0.51 mg IV 1 hr 12 min Respiratory depression, hypotension*

Flumazenil (Romazicon) 0.2 mg IV (max dose 3 mg) 3060 min 2 min Seizures

*Dose dependent when administered alone but synergistic when combined with narcotic medications.

Beware of iatrogenic overdose owing to recurrent dosing as a result of the long onset of action.

Reversal agent for benzodiazepines. Can cause seizures if administered quickly.

IV, intravenously.
From Rutter T, Tremper K. Anesthesiology and pain management. In Greeneld L, Mulholland M, Oldham K, et al (eds): Surgery: Scientic
Principles and Practice, 2nd ed. Philadelphia: Lippincott-Raven, 1997; pp 438454.

Table 53 Commonly Used Local Anesthetics

Repair
Agent Max Dose Duration Local anestheticrelated seizures should be treated
(Interstitial)
immediately with barbiturates. Generally, phenytoin is
Lidocaine (plain) 5 mg/kg 3060 min not required for long-term prophylaxis or treatment,
Lidocaine with 100 mcg epinephrine* 7 mg/kg 1.52 hr
but all patients require intensive care unit admission for
observation and treatment of recurrent seizures. No
Bupivacaine (Marcaine/Sensorcaine) 3 mg/kg 34 hr specic reversal agents are available for local anesthetic
Chloroprocaine
15 mg/kg 3060 min seizures.

Tetracaine 2 mg/kg 3 hr Prevention

*Contraindicated in organs supplied by end-arterioles. Surgeons must be familiar with the particular local

Ester class agent that can cause allergic reaction in patients allergic to
para-aminobenzoic acid (PABA).
From Rutter T, Tremper K. Anesthesiology and pain management. In
Greeneld L, Mulholland M, Oldham K, et al (eds): Surgery: Scientic
Principles and Practice, 2nd ed. Philadelphia: Lippincott-Raven, 1997;
pp 438454; and Salam GA. Regional anesthesia for ofce procedures:
part I: head and neck surgeries. Am Fam Physician 2004;69:585590.
anesthetic used, its toxic prole, and dosing limitations.
Needle aspiration should be performed prior to inject-
ing the local anesthetic to ensure interstitial (as opposed
to intravascular) injection. Finally, bier blocks are
best performed under the direction of a trained
anesthesiologist.

Inadequate Analgesia
Consequence
Aside from the emotional discomfort of pain, inade-
quate analgesia induces the stress response and causes
an increase in catecholamine release. This results in a
signicant increase in cardiac work that can result in
myocardial ischemia in patients with coronary artery
disease.
Grade 1 complication
Repair
Both local and systemic modalities of analgesia can be
used to manage pain.
Prevention
Pain is best prevented by administration of local anes-
thetic prior to any skin incision. Signs such as hyperten-
sion, tachycardia, and tachypnea should be monitored
as indices of pain in patients who are unable to com-
municate. Furthermore, administration of long-acting
local anesthetic at the completion of the procedure can
provide comfort in the immediate postoperative period
while waiting for long-acting systemic analgesics (such
as oxycodone) to take effect.
Inadequate Amnesia/Anxiolysis
Consequence
As with inadequate analgesia, inadequate anxiolysis and
amnesia cause an increase in catecholamine release and
cardiac work.
Grade 1 complication
Repair
Although high doses of narcotic can cause anxiolysis,
this feeling is best controlled with benzodiazepines or
propofol. Of note, both agents can cause signicant
dose-related respiratory depression and hypotension, as
discussed later.
Prevention
Although small doses of benzodiazepines can be used
to provide both anxiolysis and amnesia before and
during the start of a procedure, propofol is now the
preferred agent owing to its rapid onset/offset prole.4
Increasingly, automated infusion of propofol or other
sedatives is being used to ensure a constant blood con-
centration of agent. Studies have shown that patients
prefer such dosing regimens and require less total drug
than regimens utilizing bolus doses.57
Respiratory System
One of the most common serious adverse events associ-
ated with surgeon-delivered anesthesia is airway compro-
mise.8 This is most commonly seen in patients receiving
conscious sedation.
5 ANESTHESIA FOR THE SURGEON 51
Delay in Control of the Airway and Failure to
Recognize Respiratory Compromise
Consequence
Inability to recognize oversedation, hypoxemia, or
hypercapnea causes a delay in obtaining expedient
control of the airway. This can result in aspiration,
altered blood gases, hypoxic brain injury, or cardiac
failure. Furthermore, persistent bag-valve ventilation
and inability to quickly intubate patients increase the
risk of vomiting and aspiration.
Respiratory depression can result in impaired oxygen-
ation and/or ventilation. Either of these results can lead
to depressed mental status and inability to protect the
airway. Furthermore, circulatory derangement (hypoten-
sion, bradycardia) can occur if carbon dioxide levels
increase or oxygen levels decrease rapidly.
Grade 4/5 complication
Repair
All surgeons administering conscious sedation should
be trained and comfortable with orotracheal intubation
and must have all necessary equipment and medications
readily available. At a minimum, all surgeons must have
a bag-mask and either oropharyngeal or nasopharyn-
geal airway immediately available to temporarily control
ventilation while arrangements are made for more
denitive airway management.
Prevention
Both the surgeon and the staff should be trained in
recognizing signs of inadequate ventilation. These signs
may include increased work of breathing, which often
manifests as paradoxical movement of the chest and
abdomen or use of accessory muscles; agitation or con-
fusion; and decreased sensorium. The surgeon should
not wait for hypoxemia (desaturation) to develop
before intervening and should be familiar with the dose
and duration of effect of reversal agents (see Tables
51 and 52). Ultimately, it is critical to remember that
the decision to intubate a sedated patient is a clinical
one and the surgeon should not wait for conrmatory
tests or maneuvers prior to intervening if she or he feels
that the airway or respiratory system is compromised.
It is important for the surgeon to assess the adequacy
of the patients airway and pulmonary reserve prior to
administering a sedative or analgesic agent. Assessment of
the airway should include the Mallampati score (ability to
visualize the tonsillar pillars), ability to open the mouth
fully, submental distance, degree of neck mobility, and
presence of facial hair. It has been shown that increasing
Mallampati score, inability to open the mouth more than
two nger widths, and submental distance less than three
nger widths are associated with difculty with orotra-
cheal intubation.9 Furthermore, facial hair can make bag-
mask ventilation difcult by preventing the mask from
sealing around the mouth adequately.
 52 SECTION I: GENERAL CONSIDERATIONS
Medication-Related Respiratory Depression
Consequence
As noted previously, respiratory depression can result
in impaired oxygenation and/or ventilation with resul-
tant circulatory collapse and altered mental status.
Grade 1/4 complication
Repair
The narcotic antagonist naloxone can be used to reverse
the respiratory effects of narcotics, and umazenil
(Romazicon) can be used to reverse the effects of
benzodiazepines. However, the half-life of either agent
is much shorter than the drug against which it is
directed. Therefore, patients need to be monitored very
carefully for recurrence of the side effects. Also, rapid
administration of either reversal agent can induce with-
drawal and, in the case of umazenil, seizures. Patients
who continue to require reversal agent owing to sig-
nicant overdose should be intubated and mechanically
ventilated until the respiratory depressive effects of the
medication(s) have fully resolved.
Prevention
Most medications used for analgesia and amnesia/
anxiolysis can cause respiratory depression. This life-
threatening complication can be prevented most
effectively by using only small, incremental dose of
medications and being mindful of the synergistic (not
additive) effects of opioids and benzodiazepines.
Cardiovascular System
Hypotension
Opioid medications provide mainly analgesia with little to
no cardiac depression. However, they cause varying
degrees of histamine release. Histamine release is primar-
ily caused by morphine, followed by hydromorphone, and
is least likely to occur with fentanyl. Other commonly
used sedatives, such as propofol and benzodiazepines,
have a direct vasodilatory effect.
Consequence
Histamine release can result in peripheral vasodilatation
and hypotension in the preload-dependent (hypovole-
mic) patient. Similarly, benzodiazepines and propofol
can cause hypotension if given quickly or in high doses,
especially in volume-depleted patients.
Grade 1 complication
Repair
Medication-related hypotension can be treated in
almost all cases with intravenous uids alone. Rarely, a
small dose of an 1-receptor agonist (e.g., phenyleph-
rine) may be needed to temporarily control the blood
pressure while uid resuscitation is continued.
Prevention
The vasodilatory effects of medications can be mini-
mized by slow administration of small doses. Further-
more, adequate hydration prior to administration of
moderate to high doses will further decrease the hypo-
tensive effects of the medication(s), although this sce-
nario is most often addressed in the inpatient setting,
in which deeper sedation is often required.
End-Organ Ischemia
Consequence
Use of local anesthetics containing epinephrine in end-
organs can cause ischemia owing to vasospasm.
Although rare, ischemia can threaten end-organ
viability.
Grade 4 complication
Repair
No specic therapy exists to reverse the vasoconstrictive
effects of epinephrine on terminal arterioles. The patient
should be kept well hydrated to maximize perfusion
until the effects of epinephrine wear off.
Prevention
Epinephrine-containing local anesthetics should not be
used near organs supplied by a terminal arteriole. Such
organs include ngers, toes, ears, tip of the nose, and
penis.
Bupivacaine-Induced Arrhythmia
Consequence
Intravascular injection of bupivacaine or toxic doses of
bupivacaine can induce potentially lethal ventricular
dysrhythmias. Such dysrhythmias are characteristically
nonreversible and, thus, frequently fatal.
Grade 5 complication
Repair
Standard advanced cardiac life support measures should
be instituted. However, patients are rarely resuscitated
from a dysrhythmia related to an intravascular injection
of bupivacaine or overdose.
Prevention
As noted previously, needle aspiration should be
performed prior to injecting the local anesthetic to
ensure interstitial injection, and the surgeon must
be familiar with the dosing regimen for bupivacaine.
Table 53 contains the dosing and pharmacologic
prole of bupivacaine and other commonly used local
anesthetics.
Hematologic System
Methemoglobinemia
A common anesthetic pitfall that can acutely affect the
surgical patient hematologically is methemoglobinemia
resulting from aerosolized anesthetic used for endoscopic
 5 ANESTHESIA FOR THE SURGEON 53

procedures. Lidocaine; benzocaine, tetracaine, and but-

amben (Cetacaine); have been associated with methemo-
globinemia, with Cetacaine implicated most often.10,11
Consequence
Because methemoglobin cannot transport oxygen,
peripheral tissues are rendered ischemic, and profound
acidosis with cardiovascular collapse can occur quickly.12
Patients will become cyanotic, and the pulse oximeter
will show low-normal oxygen saturation despite the
nding of high dissolved oxygen on an arterial blood
gas sample.
Grade 1/2 complication
Repair
The most effective treatment for methemoglobinemia
is intravenous methylene blue (12 mg/kg; maximal
dose is 7 mg/kg). This reduces the iron in the heme
molecule back into a state at which it can once again
transport oxygen. Reversal of cyanosis and recovery of
cardiovascular instability should be noted in 20 to 40
minutes. Of note, intubation and mechanical ventila-
tion with high inspired oxygen levels will not be of
assistance.
Prevention
The most effective way to prevent this occurrence is
to use as little topical anesthetic as possible. Although
the exact mechanism underlying this disorder is not
known, most reports suggest it is a dose-dependent
phenomenon.
PITFALLS FOR SPECIFIC BLOCKS 13
The landmarks for each of the blocks discussed later are
summarized in Table 54. In addition, Figures 51 to
54 depict the anatomic location for each injection.
Ilioinguinal Nerve Block
The addition of ilioinguinal nerve block to the anesthetic
regimen used for inguinal herniorrhaphy is associated with
a lower cost and higher patient satisfaction score than
those of general anesthesia or systemic sedation with local
anesthesia alone.14,15 A 10- to 20-ml mixture of 0.25%
bupivacaine and 1% lidocaine is injected through all layers
of the anterior abdominal wall approximately 1.5 cm
medial to the anterior superior iliac spine (see Fig. 51).
This block is not intended to be used as the sole modality
for analgesia during inguinal herniorrhaphy; rather, it is
meant to supplement an overall regimen so as to provide
better postoperative pain control and facilitate discharge
from the recovery area.
Consequence
Failure to anesthetize the ilioinguinal nerve can result
from poor injection technique. This can be due to
failure to inject deep to the oblique muscles of the
anterior abdominal wall or to failure to inject a suf-
cient amount of agent.
Although it is possible to injure the cecum or sigmoid
colon during this procedure, there are no reports of bowel
injury resulting from this injectionmost likely because a
small-bore needle is used, and unintentional injection into
the bowel is innocuous. The consequence of such an injec-
tion will be inadequate analgesia and postoperative pain.
Grade 1 complication
Repair and Prevention
Because the purpose of this block is postoperative pain
control, it is very difcult to assess whether proper
technique has been used intraoperatively. Deep inltra-
tion with 20 ml of local anesthetic injected along the
needle tract during needle withdrawal is the best
method to try to ensure adequate neural blockade.

Table 54 Landmarks for Regional Blocks

Type of Block Landmarks Comments

Finger 1 cm distal to the webspace, along the radial and ulnar sides of Epinephrine-containing anesthetics are contraindicated
the nger

Median nerve Deep to the exor retinaculum, between the tendons of the Aspirate prior to injection to avoid inadvertent arterial
exor carpi radialis and the palmaris longus or just lateral to injection
the tendon of the exor carpi radialis

Ulnar nerve Deep to the exor retinaculum, medial to the tendon exor carpi Usually requires two separate injections to anesthetize
ulnaris tendon, and also along the styloid process of the ulna the dorsal and volar branches

Radial nerve Wide area extending from the snuff box toward the ulnar aspect
of the wrist

Posterior ankle 1 cm above the posterior aspect of the medial and lateral Anesthetizes sole of foot. Aspirate prior to injection to
malleoli, deep to the exor retinaculum avoid injection into the posterior tibial artery/vein

Anterior ankle 1 cm above the anterior aspect of the medial and lateral malleoli Anesthetizes the dorsum of the foot

From Salam GA. Regional anesthesia for ofce procedures: part II: extremity and inguinal area surgeries. Am Fam Physician 2004;69:896900.
 54 SECTION I: GENERAL CONSIDERATIONS
Iliohypogastric n.
Ilioinguinal n.
Transvers abdominus m.
Internal Oblique m.
External Oblique m.
Lateral cutaneous branch of
subcostal n.
2
1
Inadvertent Femoral Nerve Block
Consequence
Injection of an excessive amount of local anesthetic or
injection in the incorrect plane at the time of attempted
placement of ilioinguinal nerve block can result in
transient femoral nerve palsy. This complication has
been reported in 5% of adults and 10% of children
undergoing elective inguinal herniorrhaphy.16,17 Until
the block resolves, patients will complain of signicant
weakness or inability to bear weight on the affected
extremity.
Grade 1 complication
Repair
This block is most often detected in the recovery room
after the patient attempts to ambulate, and it cannot
be reversed once it occurs. The duration of the block
depends on the type and amount of anesthetic admin-
istered.
Prevention
The plane between the transversus abdominis and the
transversalis fascia fuses laterally with the iliacus fascia,
which contains the femoral nerve.18 It is not possible
to avoid injection between these muscles because the
Quadratus
lumborum m.
Psoas major m.
Genitofemoral n.
Femoral br.
Genital br.
Genital br.
Anterior scrotal
ilioinguinal n.
Figure 51 Ilioinguinal nerve block. Exces-
sive injection of anesthetic can result in
femoral nerve palsy, whereas inappropriately
placed injectate will manifest as ineffectual
analgesia postoperatively.
surgeon cannot discriminate between them during a
percutaneous injection. However, this complication
can be avoided by limiting the volume of injectate and
thus limiting the amount of anesthetic that can pool
around the femoral nerve.
Finger Block
Two nerves travel on each side of each nger. The needle
is inserted 1 cm distal to the webspace at the medial and
radial sides of the digit (see Fig. 52). One milliliter to
2 ml of 1% lidocaine or 0.25% to 0.5% bupivacaine is
injected.
Intravascular or Intraneural Injection
Consequence
Intravascular or intraneural injection of local anesthetic
can have local and/or systemic manifestations. Locally,
a hematoma may cause short- to moderate-term neu-
ropraxia and/or pain or ischemia. As discussed
previously, systemic manifestations can range from
hypotension to seizures, depending on the agent(s)
injected. As noted in the section on end-organ isch-
emia, epinephrine-containing anesthetics are abso-
lutely contraindicated for this particular block and
should not be used.
Grade 4/5 complication

Needle entry sites
Dorsal digital n.
Dorsal digital n.
Proper palmar digital n.
Figure 52 Digital block. Note the proximity of the vessels to
the digital nerves. Epinephrine-containing solutions are absolutely
contraindicated because they can result in profound arteriole spasm
and digital ischemia. Furthermore, the volume of injectate should
be limited to minimize compression of the vessels.
Repair
Little treatmentother than elevation, warm com-
presses, and hydration to optimize blood ow to the
affected extremityis possible for local complications.
The treatment of systemic toxicity is discussed
previously.
Prevention
The best way to prevent such complications is to aspi-
rate prior to injecting the anesthetic to ensure intersti-
tial inltration as opposed to intravascular injection.
Furthermore, anesthetic should not be injected if the
patient complains of shooting or electric pain on
needle entry. Such symptoms suggest intraneural place-
ment of the needle. The needle should be removed
and reinserted. As already mentioned, epinephrine-
containing anesthetics should not be used for digital
blocks.
Median Nerve Block
The median nerve provides sensation to the radial aspect
of the palm, the volar surface of the rst three digits
(thumb, index, and middle nger), and the radial half of
the ring nger.
Incorrect Positioning of the Needle for Injection
Consequence
Incorrect identication of the necessary landmarks for
injection will result in ability to adequately anesthetize
the hand.
Grade 1 complication
5 ANESTHESIA FOR THE SURGEON 55
Repair
The landmarks at the wrist should be identied, as
instructed later, and a new attempt should be made to
anesthetize the hand. Three milliliters to 5 ml of anes-
thetic are usually sufcient to adequately anesthetize
the hand.
Prevention
As depicted in Figure 53, the median nerve travels
deep to the exor retinaculum at the wrist, medial to
the ulnar aspect of the exor carpi radialis (FCR). The
tendon of this muscle can be noted by asking the
patient to ex the wrist. Anesthetic is then injected just
medial to the medial border of the FCR tendon. Also,
anesthetic can be injected in the space between the
tendons of the FCR and the palmaris longus. This space
is identied by asking the patient to ex the wrist and
oppose the thumb and fth digit. The correct depth
for injection is felt as a loss of resistance as the needle
passes through the exor retinaculum.
As with nger blocks, care must be taken to ensure that
neither vascular or intraneural injection takes place.
Ulnar Nerve Block
The ulnar nerve provides sensation to the surfaces of the
palm and ngers not covered by the median nerve and
also to the dorsal surface of the hand.
Inappropriate needle placement has the same conse-
quences and repair as those discussed previously regarding
median nerve blocks. The ulnar nerve divides in the area
of the wrist to innervate the volar and dorsal aspects of
the hand. The volar branch is anesthetized by injecting
lateral to the tendon of the exor carpi ulnaris, taking care
to ensure that intravascular injection into the ulnar artery
does not occur. The dorsal branch is anesthetized by
placing the anesthetic along the styloid process of the ulna
(see Fig. 53).
Radial Nerve Block
The radial nerve provides sensation to the dorsum of the
hand and the rst three ngers proximal to the distal
interphalangeal joint. A broad area along the dorsal aspect
of the wrist must be inltrated to anesthetize this area.
Injection is begun in the area of the snuffbox and extended
to the ulnar side of the wrist along the dorsal aspect of
the hand. Because this injection is not near major blood
vessels, the chance of inadvertent intravascular injection is
lessened.
Ankle Block
Local anesthetic cannot be used to anesthetize only a
portion of the sole of the foot owing to marked pain
associated with the procedure. As such, a regional
(ankle) block is needed. The sole of the foot is anesthe-
tized utilizing a posterior ankle block, whereas the dorsum
 56 SECTION I: GENERAL CONSIDERATIONS
Ulnar styloid
process
Ulnar n.
Ulnar artery
Flexor carpi
A radialis tendon
B injection.
of the foot is made insensate using an anterior ankle
block.
Incorrect Positioning of the Needle for Injection
Consequence
As with the blocks noted previously, incorrect identi-
cation of the necessary landmarks for injection will
result in nonsatisfactory anesthesia.
Grade 1 complication
Repair
The landmarks at the ankle should be identied, as
instructed later, and a new attempt should be made to
anesthetize the foot. Ten milliliters of anesthetic is
usually sufcient to adequately anesthetize each aspect
of the foot.
Prevention
As seen in Figure 54, the nerves that have to be anes-
thetized for a posterior ankle block are the sural nerve
and tibial nerve. The sural nerve is best accessed 1 cm
above and posterior to the lateral malleolus. The tibial
nerve is located posterior to the posterior tibial artery
Median n.
Distal radial
prominence
Radial artery
Flexor carpi
radialis tendon
Palmaris
longus tendon
Figure 53 Median and ulnar nerve
blocks. Care must be taken to prevent
either intraneural or intra-arterial
and deep to the exor retinaculum. It is best anesthe-
tized by inserting the needle 1 cm above and posterior
to the medial malleolus, taking care to aspirate prior
to injection to avoid intra-arterial injection. As with
inltration of the median and ulnar nerves, loss of
resistance indicates that the needle has passed through
the exor retinaculum and is at the proper depth for
injection.
An anterior ankle block is done by anesthetizing the
supercial peroneal and saphenous nerves. The supercial
peroneal nerve is blocked by injecting just above and
anterior to the lateral malleolus. The saphenous nerve is
blocked by injecting just above and anterior to the medial
malleolus.
INPATIENT ANESTHETIC PITFALLS
FOR THE SURGEON
Preoperative Medications
In general, all preoperative medications that do not inter-
fere with the planned procedure (such as anticoagulants)
should be continued the day of surgerythis is especially
 5 ANESTHESIA FOR THE SURGEON 57

Ankle Section

A 2
1

Tibialis anterior
tendon

Superficial
Deep peronal n. peroneal n.
Saphenous v.
Saphenous n.

Tibialis posterior Tibia

tendon
Posterior tibial a. Fib
Posterior tibial n.

Fibular brevis m.

Calc
Sural n.

1 2
Figure 54 Ankle block.

true of antihypertensive medications, most notably -
blocking agents. Current literature suggests that appropri-
ately administered -blockade started weeks prior to
surgery reduces perioperative ischemia and may reduce the
risk of myocardial infarction (MI) and death in high-risk
patients.1922 Perioperative 2-agonists may have similar
effects.23,24
Consequence
Stopping medications acutely can result in impaired
homeostasis. This is classically noted when clonidine is
stopped. A severe rebound tachycardia can occur. Sim-
ilarly, serum levels of most antiseizure medications can
drop precipitously if more than one dose is omitted
from the daily regimen.
Steroids should be continued perioperatively, although
there are neither level I nor II data to guide management
of patients who are on chronic steroids. Although many
surgeons and anesthesiologists also give at least one
stress dose of steroid (100 mg hydrocortisone intrave-
nously) at the time of induction to possibly prevent addi-
sonian crisis, little evidence supports this practice, and the
decision to administer steroids must take into account the
anticipated surgical stress and probability of adrenal insuf-
ciency. In a review article, Salem and colleagues25 sum-
marized the current role of perioperative steroids and
offered guidelines to the need for supplemental periop-
erative dosing.
Grade 1/2 complication
Repair and Prevention
Patients should be instructed to stop preoperative
medications only when absolutely necessary. Most fre-
quently, this involves stopping anticoagulants. In this
situation, the time that the patients coagulation param-
eters are normalized should be kept to a minimum,
depending on the reason underlying the need for anti-
coagulation. When possible, aspirin and/or clopidro-
grel should be continued.
Patients on chronic -blocking agents should be
given an intravenous -blocker until they are able to
 58 SECTION I: GENERAL CONSIDERATIONS
take oral medications postoperatively. This is a core
measure monitored by the Centers for Medicare and
Medicaid Services.26
Postoperative dosing of pain medication should be
adjusted to accommodate the tolerance that patients
on chronic opioids develop. It is common for patients
with chronic pain to require dosages up to 10 times
higher than that required to obtain analgesia in a
patient who is opioid nave.27
Patients with diabetes should be instructed to take half
of their normal dose of short-acting insulin on the
morning of surgery. Their procedures should be
scheduled as morning cases to minimize their nothing-
by-mouth (NPO) time. Patients should be instructed
to refrain from taking any long-acting insulin or oral
hypoglycemic drug on the day of surgery.28
Neurologic Pitfalls
Exacerbation of Cervical Spine Injury
during Intubation
Cervical spine injuries may easily be worsened with neck
exion or extension during intubation. The majority of
injuries are due to fracture and dislocation of the vertebral
column.
Consequence
Exacerbation of a cervical spine injury can result in
signicant (and possibly permanent) neurologic dys-
function, including high spinal paralysis.
Grade 4 complication
Repair and Prevention
Although it is controversial whether a rigid cervical
collar must be kept in place during direct laryngoscopy,
it is essential to maintain in-line cervical traction
throughout the intubation process. Furthermore, a
beroptic bronchoscope may be used instead of direct
laryngoscopy to secure the airway in patients with a
known or suspected unstable cervical spine injury.2931
Paralyzed Patients
The level of injury or lesion and time since injury of
patients with known spinal cord disease presenting for
elective or semielective surgery are of critical importance.
Overactivity of the sympathetic nervous system is common
with transactions at T5 or above but is unusual with inju-
ries below T10 and usually presents days to weeks after
injury.32
Consequence
Transection of descending inhibitory neurons leaves
the spinal cord with innate excitatory reexes. These
reexes can potentially lead to autonomic hyperreexia
with minimal surgical stimulation. Such stimulation
may lead to intense uninhibited sympathetic discharge
and profound tachycardia and hypertension.
Grade 1 complication
Repair and Prevention
The anesthesiologist must be notied preoperatively
of the level and timing of the injury in order to be
prepared for this hyperreexic state. Pharmacologic
intervention may be needed to restore homeostasis
intraoperatively with the use of potent arterial and vaso-
dilators such as sodium nitroprusside, nitroglycerin,
and/or nicardipine.
Patients with Peripheral Motor Neuropathy or
History of Stroke
Patients presenting with a history of stroke, spinal cord
injury, or peripheral motor neuropathy (secondary to
Guillain-Barr, polio, amyotrophic lateral sclerosis, myas-
thenia gravis, musculodystrophy) have a potentially unique
muscle physiology that warrants further examination to
plan the proper anesthetic regimen. The time since infarct
or onset of disease is very important to the anesthesiolo-
gist, who may be required to administer a depolarizing
muscle relaxant (succinylcholine) to facilitate intubation.
Consequence
Patients with neuromuscular disorders are prone to
severe hyperkalemia after administration of succinyl-
choline, a depolarizing muscle relaxant. The hyperka-
lemic response is directly related to the amount of
paralyzed muscle mass and the time lapse since insult
owing to up-regulation of the acetylcholine receptor in
paralyzed muscle.33 Severe hyperkalemia can result in a
fatal cardiac dysrhythmia.
Grade 5 complication
Repair
Patients with sudden cardiac dysrhythmia after admin-
istration of succinylcholine should be suspected of
having severe hyperkalemia (Box 51). In addition to
standard advanced cardiac life support, measures
directed at acutely lowering the serum potassium level
should be instituted immediately. Such measures
include the judicious use of calcium gluconate or chlo-
Box 51 Conditions Causing Susceptibility to
Hyperkalemia after Succinylcholine Administration
Extensive burn injury (>24 hr old)
Massive trauma
Spinal cord transection (>48 hr)
Acute renal failure
Stroke
Massive trauma/crush injury
Prolonged immobility (>7 days)
Guillain-Barr syndrome
Severe Parkinson disease
Acute tetanus exacerbation
Acidosis with hypovolemia
Profound sepsis
Severe intra-abdominal sepsis
Congenital muscle diseases

Table 55 Complications of Malignant Hyperthermia
Sign Physiologic Effect
Muscle rigidity/spasm Inability to ventilate, hyperkalemia
Hyperkalemia Cardiac dysrhythmia
Rhabdomyolysis, Renal failure
myoglobinuria
Increase metabolism, Cardiovascular collapse due to extreme
acidosis tachycardia or severe acidosis, hypoxemia
Fever (late sign) Seizures, cerebral edema, brain anoxia
ride, intravenous insulin and dextrose 50%, sodium
bicarbonate, and hyperventilation.
Prevention
Nondepolarizing muscle relaxants should be used in this
patient population to avoid potential hyperkalemia.
Malignant Hyperthermia
Patients with musculodystrophy, central cord disease,
osteogenesis imperfecta, and those with a family history
of malignant hyperthermia (MH) are at risk for develop-
ing this syndrome.
Consequence
MH is a rare (1 : 15,000) life-threatening condition
that can develop as a result of volatile anesthetic or
succinylcholine administration. It is characterized by an
acute hypermetabolic state occurring up to 24 hours
after administration of a volatile general anesthetic or
succinylcholine. The consequences of this syndrome
are listed in Table 55. Life-threatening complications
can include muscle rigidity, which can prevent adequate
ventilation; severe hyperkalemia and cardiac dysrhyth-
mia; myoglobinuria and acute renal failure; severe
hyperthermia, leading to seizures and brain anoxia or
cerebral edema; and metabolic acidosis and cardiovas-
cular collapse.34,35
Grade 1/4/5 complication
Repair
If MH occurs intraoperatively, then surgery must be
aborted as expediently as possible. Dantrolene is the
only approved medication for the treatment of MH. Its
mechanism of action involves stabilization of the sar-
coplasmic reticulum to prevent further release of
calcium from the skeletal muscle stores and ongoing
muscle contraction. The dose is 2.5 mg/kg every 5
minutes until symptoms abate or until a maximum
dosage of 10 mg/kg is reached, and then 1 mg/kg
every 6 hours for 24 to 48 hours. All patients should
be cooled aggressively with ice packs and intubated
with 100% oxygen with hyperventilation to meet their
high oxygen and metabolic demands during the crisis
phase. Massive uid resuscitation may be needed to
prevent renal failure owing to myoglobinuria and
5 ANESTHESIA FOR THE SURGEON 59
hypovolemia resulting from severe pyrexia. Severe
hyperkalemia should be treated with insulin/glucose,
bicarbonate, uid resuscitation, and/or dialysis as indi-
cated by the patients electrocardiogram and hemody-
namic status.35
Prevention
The most effective way to prevent MH is to recognize
its risk factors, most notably family history, and avoid
the use of volatile anesthetics and succinylcholine in
these patients. The syndrome is inherited as an autoso-
mal dominant trait. Furthermore, the surgeon and
anesthesia provider must be familiar with signs of MH.
Of note, fever is a very late sign. The earliest sign of
MH is a sudden increase in the partial pressure of
exhaled carbon dioxide and masseter muscle spasm.
Patients who may have experienced MH should be
referred to the national registry for MH (1-800-MH-
HYPER) for proper evaluation and counseling.
Patients with Parkinson Disease
Patients with Parkinson disease must continue their med-
ications throughout the perioperative period. Further-
more, specic medications may worsen muscle rigidity and
should be avoided.
Consequence
Patients with Parkinson disease should continue their
medications because abrupt withdrawal may lead to
difculty with intubation and ventilation owing to
worsened muscle rigidity.
Grade 1 complication
Repair and Prevention
Phenothiazines, butyrophenones, and metoclopramide
should not be given to patients with Parkinson disease
because these agents can exacerbate symptoms as a
consequence of their antidopaminergic activity.36
Cardiovascular Pitfalls
Preoperative Evaluation and Clearance
The most common reason for delay in elective surgery is
inadequate cardiac work-up and optimization of medical
therapy in the setting of ischemic heart disease. Specic
criteria related to preoperative evaluation and medical
clearance for surgery are discussed elsewhere.
Patients with Aortic and Mitral Stenosis
Consequence
Severe aortic stenosis poses a great perioperative risk
for noncardiac surgery. If stenosis is moderate (aortic
valve orice area of 0.70.9 cm2 and aortic valve index
of 0.5 cm2/m2) with symptomatic impairment or ste-
nosis is critical (aortic valve orice area of <0.7 cm2
with an aortic valve index of <0.5 cm2/m2), then
elective surgery should be postponed until after aortic
valve replacement. Mortality risk approaches 10% in
 60 SECTION I: GENERAL CONSIDERATIONS
certain patient populations (age >70, those with chronic
renal insufciency or with insulin-dependent diabetes
mellitus) undergoing noncardiac surgery with critical
aortic stenosis.23,37
Grade 5 complication
Repair and Prevention
Because aortic and mitral stenoses demand a long dia-
stolic lling period, adequate -blockade should be
started preoperatively to avoid symptoms of heart
failure and pulmonary edema. Sinus rhythm should be
maintained with antiarrhythmic medications as needed,
and these should be continued perioperatively. Fur-
thermore, afterload-reducing agents (e.g., hydralazine
or calcium channel blocker) should not be used in
patients with aortic stenosis to maximize forward ow
and prevent heart failure. Instead, the primary goals of
hemodynamic management should focus on preserva-
tion of diastolic blood pressure and coronary perfusion
pressure at all costs to avoid hypoperfusion of the
endocardium.38
Hypotension on Induction
Many anesthetics (inhalational and intravenous) possess
potent vasodilatory and/or cardiodepressant properties.
Thus, patients frequently become hypotensive during
induction and require aggressive therapies for rapid
stabilization.
Consequence
Signicant, prolonged hypotension that lowers mean
arterial blood pressure to less than 25% of preinduc-
tion levels can lead to end-organ dysfunction, includ-
ing possibly stroke, MI, acute liver injury, acute
tubular necrosis of the kidney, retinal artery hypoper-
fusion leading to optic nerve ischemia and postopera-
tive blurred vision or blindness, and spinal cord
malperfusion.
Grade 4 complication
Repair
Treatment includes the use of volume loading and
small doses of a vasopressor such as ephedrine or phen-
ylephrine. On rare occasions, hypoperfusion of the
brainstem and coronary arteries may necessitate the use
of small bolus doses of epinephrine to regain sympa-
thetic tone and cardiac output.
Prevention
Hypertensive patients are frequently intravascularly
volume depleted, and adequate intravenous uids
should be given prior to induction of anesthesia. This
is especially true if patients are acutely ill and require
hospitalization prior to surgery.
Propofol, midazolam, and sodium thiopental are com-
monly used drugs for induction of anesthesia, but all
possess signicant potential for reducing systemic vascular
resistance. In patients who will not tolerate even minimal
hypotension, drugs such as etomidate or ketamine may be
more appropriate. Etomidate, a GABAnergic agent, has
minimal effects on the cardiovascular system and does not
release histamine. A mild reduction in peripheral vascular
resistance may lead to a slight decline in mean arterial
blood pressure, but myocardial contractility, cardiac
output, and cerebral perfusion pressure are unchanged. Of
note, etomidate has a side effect prole that includes
short-term myoclonus in 30% of individuals. Furthermore,
multiple doses of etomidate and infusions of etomidate
can dramatically suppress adrenal function, which can
result in refractory hypotension requiring steroid supple-
mentation. Etomidate has also been linked to increased
levels of postoperative nausea when used as an induction
agent.3944
Ketamine affects multiple sites throughout the central
nervous system and acts as an N-methyl-D-aspartate
(NMDA) antagonist. Its effects are to functionally and
temporarily dissociate conduction from the thalamus to the
cortical system and to the limbic system. Ketamines effects
on the cardiovascular system are primarily stimulatory in
nature, causing an increase in arterial blood pressure, heart
rate, cardiac output, and systemic vascular resistance. For
this reason, it has become a successful induction agent in
the setting of profound hypovolemia and is not recom-
mended in the setting of coronary artery disease, uncon-
trolled hypertension, congestive heart failure, or aortic
aneurysm or dissection. It is also a profound bronchodila-
tor and a salivary stimulant as well. Ketamines side
effect prole includes increased intracranial pressure and
cerebral metabolism. It is also an intense dissociative
amnestic agent that can cause unwanted hallucinations.45
Perioperative Pacemaker and Implantable
Cardioverter-Debrillator Management
Patients with pacemaker or implantable cardioverter-
debrillators (ICDs) should have their device evaluated
immediately prior to the start of the operation and imme-
diately afterward. The debrillator function should be
turned off, and the pacemaker should be in a default
demand-only mode with a set minimum ventricular rate
to avoid asystole or R-on-T phenomena during the
procedure.
Consequence
Electrocautery may generate current in the vicinity of
the device. The following may occur in response to the
extra electrical current:
Temporary or permanent resetting to a backup, reset,
or noise-reversion pacing mode is of little consequence
because the backup rate is usually sufcient to maintain
adequate cardiac output.
Temporary or permanent inhibition of pacemaker
output can cause prolonged periods of bradycar-

dia, depending on the patients endogenous heart
rate.
An increase in pacing rate owing to activation of the
rate-responsive sensor can cause erratic changes in heart
rate and cardiac output.
ICD ring due to activation by electrical noise will
result in unnecessary debrillation that may result in
myocardial injury.
Myocardial injury at the lead tip that may cause failure
to sense and/or capture.
Grade 1/2 complication
Repair
If a hemodynamically unstable rhythm becomes present
during surgery then immediate external cardioversion
is warranted and paddles should be placed as far from
the implanted device as possible to minimize myocar-
dial injury at the tips of the leads. In emergent cases,
when there is insufcient time or lack of proper equip-
ment to reprogram the ICD, a magnet can be placed
over the device intraoperatively. This reverts the pace-
maker to its backup demand-only setting and deacti-
vates the debrillation function in most (but not all)
devices.
Prevention
As noted previously, the debrillation function of the
ICD should be turned off and the pacer be placed in a
demand mode at a xed rate prior to the start of
operation, and the use of monopolar cautery should be
minimized. Adverse interactions are more likely if the
electrocautery is unipolar and return lead placement
leads the current through the axis of the pacemaker/
ICD. Finally, the anesthesiologist should know the
patients underlying rhythm and the settings of the
pacemaker and be prepared to intervene appropriately
if the cardiac rhythm changes. All ICDs should be
interrogated postoperatively and restored to their pre-
operative settings.23,46,47
Pulmonary Pitfalls
Optimization of Asthma Regimen
Consequence
Failure to optimally control asthma preoperatively can
lead to difculty ventilating the patient intraoperatively
or inability to extubate postoperatively.
Grade 1 complication
Repair
The inciting cause for the bronchospasm should rst
be established and disease-specic treatment should
be initiated. Intraoperative or postoperative asthma
exacerbation can be treated with oxygen, aggressive
bronchodilator therapy with 2-agonists, and inhaled
anticholinergics and/or inhaled or intravenous epi-
nephrine. The bronchial effects of intravenous steroids
5 ANESTHESIA FOR THE SURGEON 61
are not immediate and may take effect after 4 to 6
hours; therefore, steroids should be given early if the
patient does not respond to initial treatment. General
anesthesia with endotracheal intubation facilitates the
use of inhalational anesthetic agents, which are pro-
found bronchodilators and may serve as last-line treat-
ment of severe bronchospasm. Of note, inadequate
anesthesia is the most common cause of an asthmatic
attack during surgery.
Prevention
Preoperative wheezing or dyspnea suggests poorly con-
trolled disease. Respiratory tract infections are common
stimuli that evoke acute exacerbations of asthma; there-
fore, delaying surgery 2 to 3 weeks after clinical recov-
ery from an upper respiratory tract infection in patients
with asthma is recommended. Reex-induced laryngo-
spasm and bronchospasm may be prevented with
1 mg/kg lidocaine given intravenously 2 minutes prior
to airway manipulation. Finally, an adequate depth of
anesthesia should be maintained throughout the period
of surgical stimulation. -Blockerinduced wheezing in
patients with reactive airway disease is better treated
with inhaled anticholinergic agents (e.g., ipratroprium)
than with 2-agonists.4851
Improving Outcomes in Patients with
Obstructive Sleep Apnea
Consequence
Patients with obstructive sleep apnea (OSA) are becom-
ing increasingly more common and now approach 5%
to 9% in the general U.S. population. OSA is com-
monly found in obese, middle-aged men. OSA is now
considered a perioperative outcomes risk factor for
morbidity and mortality. The risk of postoperative epi-
sodic hypoxemia, acute hypercapnia, reintubation,
delirium, MI, unplanned postoperative intensive care
unit admission, and death is signicantly increased in
patients with OSA undergoing surgery. The need for
postoperative analgesia with narcotics places these
patients at signicantly more risk for respiratory failure,
hypoxia, and death in the immediate postoperative
period owing to their extreme sensitivity to changes in
the CO2 respiratory response curve.
Grade 2/5 complication
Repair
Supplemental oxygen and utilization of continuous
positive airway pressure (CPAP) or bilateral positive
airway pressure (BiPAP) immediately after extubation
will decrease the risk of transient hypoxia and hyper-
capnia, especially in those patients who required CPAP
at home prior to surgery. The judicious use of naloxone
to treat opioid-induced respiratory depression is accept-
able, but small doses should be given initially (40 mcg
every 2 min) until effect so as not to fully reverse the
analgesia provided.
 62 SECTION I: GENERAL CONSIDERATIONS
Prevention
CPAP training should be instituted prior to date of
surgery, and plans should be made in advance for its
use in the immediate postoperative period. The use of
CPAP immediately after extubation has been shown to
clearly decrease the development of hypoventilatory
atelectasis and hypoxemia and to improve outcomes.
Assessment of neck circumference and obtaining sleep
studies preoperatively may be benecial in the setting
of OSA to determine the amount of hypopnea, hypoxia,
and apnea experienced during sleep. Planned use of
regional anesthesia or local anesthesia infusions in
wound sites will decrease the systemic opioid pain
requirements and decrease the risk of respiratory depres-
sion leading to hypoxia and death.28,50,52,53
The Pregnant Patient
Approximately 1% to 2% of pregnant patients require
nonobstetric surgery during their pregnancy. The most
common procedures are appendectomy, cholecystectomy,
and diagnostic laparoscopy for abdominal pain. In general,
anesthesia poses a risk to the fetus throughout the gesta-
tional period, although the risk is highest during the rst
trimester and decreases thereafter. Conversely, the risk
of anesthesia to the mother is lowest during the rst
trimester of pregnancy and increases thereafter. Thus, only
urgent or emergent operations should be performed
during the pregnant state and for 6 weeks postpartum.54
Maternal Bleeding
Consequence
The pregnant patient has a high resting cardiac output
and expanded blood volume, which results in a relative
dilutional anemia. This means that the patient is able
to withstand bleeding without manifesting many of the
signs associated with impending cardiac collapse, but
she has a decreased ability to augment oxygen delivery
once a critically low hemoglobin level is reached. Failure
to appreciate subtle changes in blood pressure or heart
rate may result in shunting of blood away from the
placenta and fetal hypoxemia. The fetus cannot tolerate
a state of low oxygen delivery because it is in a relatively
hypoxic environment at baseline.
Grade 4 complication
Repair and Prevention
Bleeding must be minimized and intravenous volume
status maintained closely in the pregnant patient.
Patients beyond 16 weeks gestation should be posi-
tioned 20 to 30 left lateral decubitus to move the
gravid uterus away from the vena cava and optimize
venous return to the heart. Blood transfusion is recom-
mended early in pregnant patients whose bleeding is
not readily controlled intraoperatively. The surgeon
must keep the anesthesia provider aware of excessive
bleeding. Use of exogenous vasopressors must
be avoided because these medications also cause
shunting of blood away from the placenta and fetal
hypoxemia.54,55
Hypoxemia during Intubation
Consequence
Maternal functional residual capacity decreases mark-
edly as the uterus distends during fetal growth. Fur-
thermore, maternal and fetal metabolism cause a net
increase in maternal minute ventilation (to remove
excess CO2) and oxygen consumption. Combined,
these effects render the mother susceptible to rapid
desaturation during periods of apnea. Hypoxic episodes
are not tolerated by the fetus, which lives in a relative
hypoxic environment.
Progesterone, the dominant hormone of pregnancy,
relaxes all smooth muscle. This causes the stomach to lose
motility, and so all pregnant patients should be assumed
to have a full stomach. Failure to intubate the patient
quickly using rapid-sequence methods and the Sellick
maneuver (compression of the trachea onto the esopha-
gus) can result in aspiration during induction and is
one of the leading causes of maternal death during
anesthesia.54
Grade 4/5 complication
Repair
In situations in which the patient desaturates or aspi-
rates during induction, the patient should be immedi-
ately intubated and placed on high-ow oxygen to
minimize the hypoxic period. Failure to intubate in the
setting of full-term pregnancy warrants immediate
rescue maneuvers (as discussed later) and possible
emergency tracheostomy. Decisions regarding subse-
quent extubation must be tailored to the patients
clinical condition once it is stabilized.
Prevention
The patient should be preoxygenated while awake and
spontaneously breathing prior to induction, and only
physicians who are facile and well-versed in intubation
should attempt to intubate a patient who is pregnant.
Rapid-sequence techniques, utilizing little or no bag
ventilation and the Sellick maneuver, should be used
to reduce the likelihood of aspiration during induction.
Emergency airway equipment, including laryngeal
mask airways, oral and nasal airways, and beroptic
bronchoscopes, should be available for immediate use
in the setting of failed orotracheal intubation. These
advanced interventions are best performed by a trained
anesthesiologist.
Spontaneous Abortion and Fetal Malformation
All surgical procedures requiring more than local anesthe-
sia are associated with up to a vefold increase in the risk

of spontaneous abortion. The risk is highest during the
rst trimester and decreases thereafter. Organogenesis
takes place from the 3rd to the 8th week of gestation.
Consequence
All volatile anesthetics are presumed to be teratogenic
during the rst trimester, and all opioids and sedatives
freely cross the placental barrier. The fetus has a mark-
edly decreased ability to metabolize medications
because its liver has not fully developed. Therefore, all
medications have much more lasting effects on the
fetus than on the mother. Because of this, elective
procedures requiring more than local anesthetic or
neuroaxial blockade (e.g., spinal or epidural anesthesia)
must be avoided during the rst trimester.
Grade 4/5 complication
Prevention
Although there are no clear studies evaluating the
effects of neuroaxial blockade on the fetus during the
rst trimester, it has been shown that neuroaxial block-
ade increases uterine and placental blood ow. However,
such blockade is also more difcult to titrate and can
result in maternal hypotension. The surgeon, obstetri-
cian, and anesthesia provider must communicate to
identify patients who can be managed with neuroaxial
blockade and possibly spared the effects of general
anesthesia.55,56
The Pediatric Patient
Failure to Recognize Difcult Intubation
Consequence
Pediatric patients have a large head and tongue, an
anterior airway, and a long and oppy epiglottis. experiencing PONV within 24 hours of surgery in the
These factors make intubation in all pediatric patients
more challenging than in adults. Furthermore, an upper
respiratory tract infection within the last 2 to 4 weeks
has been shown to increase the incidence of laryngo-
spasm 5 times and postoperative bronchospasm and the
need for reintubation 10 times.
As with pregnant patients, pediatric patients have a
higher oxygen consumption and lower functional residual
capacity than adults. This means that they do not tolerate
prolonged periods of apnea and can desaturate quickly
during induction.
Grade 1 complication
Prevention
As with treating pregnant patients, only physicians
familiar with the anatomy of the pediatric airway and
well-versed in pediatric intubation should attempt this
procedure. Emergency airway equipment, including
laryngeal mask airways, oral and nasal airways, and
beroptic bronchoscopes, should be available for imme-
diate use in the setting of failed intubation.
5 ANESTHESIA FOR THE SURGEON 63
Aspiration during Induction
Consequence
Aspiration during induction can lead to respiratory
failure and the need for prolonged mechanical support,
pneumonia, or death.
Grade 2 complication
Prevention
Pediatric and adult NPO guidelines state that patients
who are eating solids or formula should be NPO 4 to
8 hours prior to induction and intubation, and patients
who are drinking clear liquids should be NPO 2 to 4
hours prior to induction and intubation, with longer
uid and solid fasts not decreasing aspiration risks.
These guidelines vary from institution to institution.
In patients with aspiration risks (i.e., status post
cerebrovascular accident, full stomach, small bowel
obstruction, hiatal hernia, diabetic with gastroparesis,
trauma, pregnancy, pain/stress, esophageal disease,
poor level of consciousness and motor control), rapid-
sequence induction with Sellick maneuver should be
performed and the patient should be NPO from all oral
intake for at least 8 hours prior.53,57 The current evi-
dence shows that most healthy ambulatory patients
have a very low incidence of clinically signicant aspira-
tion during general anesthesia. The best preventive
strategy involves making sure solids, especially fatty
foods, are prohibited.
Preoperative Evaluation for Postoperative
Nausea and Vomiting
Postoperative nausea and vomiting (PONV) remains a
common complication after general and regional anesthe-
sia, with 25% of patients who undergo general anesthesia
United States.58,59 It is a leading cause of unanticipated
hospital admission and a limiting factor in early discharge
after ambulatory surgery. Some studies suggest that
patients are more concerned with avoiding PONV than
with avoiding postoperative pain.58,60
Consequence
Vomiting and retching can lead to potential aspiration,
increased myocardial oxygen demand, and demand-
related ischemia and can weaken or disrupt fascial
closure.
Grade 1/3 complication
Repair
PONV should be treated immediately and aggressively.
Table 56 lists some of the common drugs used in
treatment, but knowledge of their side effect proles
and contraindications should be noted before adminis-
tration. Although nonpharmacological techniques such
as acupuncture, transcutaneous electrical nerve stimula-
tion (TENS), and hypnosis have been shown to be
 64 SECTION I: GENERAL CONSIDERATIONS

Table 56 Antiemetics, Mechanism of Action, and Timing in Adults

Drug Mechanism Appropriate Timing Pitfalls and Side Effects

Ondansetron 5-HT3 Antagonist End of surgery No adverse events related to recurrent or high dosing

Dexamethasone Anti-inammatory Beginning of surgery No adverse effects related to single pre-/intraoperative dose
No effect on PONV if given late after induction

Droperidol Dopaminergic antagonist/ End or beginning of surgery Extreme sedation and dystonia, EPS at high doses,
GABAnergic prolonged QT syndrome and torsades de pointes

Ephedrine Indirect sympathomimetic Unknown Severe hypertension and tachycardia in high doses

Promethazine H1 Antagonist, End of surgery Extreme sedation, confusion, EPS, respiratory depression at
Dopaminergic antagonist high doses

Scopolamine patch Anticholinergic Night before surgery Sedation, confusion

EPS, extrapyramidal symptoms; 5-HT3, serotonin; PONV, postoperative nausea and vomiting.
From Gan T, Meyer T, Apfel C. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003;97:6271.

Box 52 Risk Factors for Postoperative Nausea Box 53 Strategies to Reduce Baseline Risk of
and Vomiting Postoperative Nausea and Vomiting
High Risk Regional anesthesia
Female Sex Propofol for induction and maintenance of anesthesia
History of PONV or motion sickness Supplemental oxygen
Nonsmoking status Avoidance of dehydration
Use of intraoperative or postoperative opioids Avoidance of nitrous oxide
Avoidance of inhalational volatile anesthetics
Medium Risk Minimization of perioperative opioids
Use of volatile anesthetics within 02 hr of emergence Avoidance of neostigmine
Nitrous oxide
Duration of surgery From Gan T, Meyer T, Apfel C. Consensus guidelines for managing
postoperative nausea and vomiting. Anesth Analg 2003;97:6271.
Type of surgery: laparoscopy, orthopedic, ENT,
strabismus, neurosurgery, plastic, and breast surgery

ENT, ear, nose, and throat; PONV, postoperative nausea and
vomiting.
From Gan T, Meyer T, Apfel C. Consensus guidelines for managing
postoperative nausea and vomiting. Anesth Analg 2003;97:6271.
effective in preventing PONV in some patients when
performed before surgery, current recommendations
do not support their use in the acute setting of
PONV.58
Prevention
Proper treatment and prophylaxis against PONV remain
controversial, but it is clear that universal prophylaxis
against PONV with current modes of therapy is not
cost effective.58 Low-risk patients may require no pro-
phylactic therapy, but high-risk patients should be pre-
treated aggressively with triple therapy because
PONV can be as frequent as 70% to 80% after surgery
in this group. Triple therapy includes, but is not limited
to, any three of the medications listed in Table 56
given in appropriate dosing and properly timed.
The rst steps in the prevention of PONV are to iden-
tify those patients at highest risk and to reduce baseline
risk factors. Box 52 lists the risk factors for PONV. The
incidence of PONV increases with increasing number of
risk factors, with the greatest risk factors being (1) female
gender, (2) history of PONV or motion sickness, (3)
nonsmoking status, and (4) the use of intraoperative and
postoperative opioids.61,62 The risk of PONV approaches
80% if all four of these factors are present. Strategies for
reducing these risks are listed in Box 53. General anes-
thesia is associated with an 11-fold increased risk for
PONV over that of regional anesthesia. Propofol is far
superior to any other induction drug in preventing
postoperative nausea. Oxygen supplementation, adequate
hydration, avoidance of nitrous oxide and volatile anes-
thetics (e.g., isourane, desurane), and minimizing
opioid use are all recommended strategies for reducing
risk and should be incorporated in a multimodal
approach.62
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during pregnancy and fetal outcome. Am J Obstet
Gynecol 1980;138:11651167.
57. Goresky G, Maltby J. Fasting guidelines for elective
surgical patients. Can J Anaesth 1990;37:493.
58. Gan T, Meyer T, Apfel C. Consensus guidelines for
managing postoperative nausea and vomiting. Anesth
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59. Sinclair D, Chung F, Mezei G. Can postoperative nausea
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score for predicting postoperative nausea and vomiting.
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63. Rutter T, Tremper K. Anesthesiology and pain manage-
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585590.
6
General Laparotomy
Russell J. Nauta, MD
INTRODUCTION
Conviction that one should undertake only an invasive
procedure whose complications one can manage is a fast-
fading tenet as increasing numbers of nonsurgical special-
ists attempt invasive procedures. The granting of privileges
in abdominal surgery, however, still assumes that the indi-
vidual so honored will be able to plan an approach, accom-
modate to the sequelae of previous abdominal surgery,
enter the abdomen, accomplish the intended task, repair
or otherwise manage injuries created while doing so, deal
with the sequelae of inammation, treat infection, and
deliver postoperative care with minimal assistance.
No amount of technical expertise trumps careful preop-
erative planning. Strategies to avoid traumatic entry into
the peritoneal cavity, preoperative determination of the
need for mechanical and antibiotic bowel preparation,
choice of incision, and planning optimal exposure are as
important as intra-operative technical judgment and facil-
ity with the instruments. In some cases, the surgeon may
have weeks to contemplate these issues, whereas in more
urgent situations, such as frank peritonitis, ruptured viscus,
leaking aneurysm, or trauma, the planning stage is sig-
nicantly truncated. Patients who have had prior abdom-
inal surgery or exposure to radiation, in particular, require
extensive contingency planning by the operating surgeon.
Previously radiated patients may be particularly unforgiv-
ing of operative misadventure because radiation may
impede repair mechanisms and both the cellular and the
vascular phases of wound healing.1
Unlike laparoscopic surgery, in which incision choice is
often dictated by optical considerations, instrument trajec-
tory, and vantage point, the surgeon performing open
surgery can select from several standard incisions. However,
not all incisions adapt well to unexpected operative nd-
ings. Traditionally, operations in which the exact source
or extent of acute intra-abdominal pathology is not known
are approached through an abdominal midline incision,
which can be readily extended in either direction, as dic-
tated by operative ndings. In the case of patients with a
previous midline incision, the incision at reoperation is
often begun well above or below the previous laparotomy
scar to permit atraumatic entry into the peritoneum. Prag-
matically, the midline incision is also useful for operations
on large abdominal tumors or spleens, which, because of
their size, may not be able to be delivered through a
transverse incision. Caudad extension of a midline incision
allows improved exposure of pelvic tumors, whereas ceph-
alad extension facilitates release of the colonic exures.
Detailed knowledge of embryology and anatomy begets
well-vascularized incisions and tension-free, well-perfused
anastomoses. For example, a surgeon familiar with the
trajectory of counterclockwise midgut rotation about the
superior mesenteric vessels during the second trimester
of gestation2 can draw on the knowledge to reverse the
process at operation to facilitate tension-free low pelvic
anastomosis of the colon (Fig. 61) or to expose the
lateral retroperitoneum in the avascular planes described
by Cattell, Braasch, and Maddox and associates (Figs.
62 and 63).3,4
Some have advocated avoidance of midline incisions
because of controversial concerns related to structural
weakness and attenuated blood supply. Evidence support-
ing these misgivings is not convincing in studies in animals
or humans, but transverse incisions may have other advan-
tages. Sometimes, selecting a low transverse incision over
a midline incision extending more cephalad will favorably
affect pulmonary toilet and maintain functional reserve
capacity without compromising intra-abdominal expo-
sure. The right lower quadrant (RLQ) transverse incision,
for example, both allows for optimal operative exposure
and facilitates pulmonary toilet in resection of cecal
cancers. In the upper abdomen, transverse incisions can
facilitate open packing or repetitive entry, as when mul-
tiple sequential laparotomies are required for the dbride-
ment of pancreatic necrosis. A once-common belief that
muscle-dividing transverse incisions or muscle-reecting
paramedian incisions convey additional strength solely
because of their multiple separately closed fascial layers or
superior blood supply is also unsupported by experimental
or clinical evidence. Indeed, a contradicting body of evi-
dence supports the superiority of mass closure over layered
closure even in areas off the midline, where multiple fascial
layers exist (Fig. 64).5
In circumstances in which the pathology is condently
delineated by a preoperative history, physical examination,
and/or preoperative imaging studies, it may be preferable
to use one of a number of anatomically dened specialty
 68 SECTION I: GENERAL CONSIDERATIONS

Superior
mesenteric
artery

Superior
mesenteric
artery

B
Figure 61 A, In the second trimester of embryologic life, the cecal bud migrates 270 counterclockwise from a position in the left
lower quadrant to ultimately assume its characteristic anatomic position in the right lower quadrant. The superior mesenteric artery serves
as the axis of this rotation. Because the aortic blood supply from which the colonic vessels ramify is in the midline, the rotation leaves the
gutters themselves avascular. The white line of Toldt represents the avascular plane for incision and is the anterior conuence of the
colonic visceral peritoneum with the parietal peritoneum of the lateral abdominal wall. B, When a segment of the left colon is removed,
embryologic rotation is reversed to allow the proximal end to be brought into tension-free apposition to the distal end for anastomosis.
 6 GENERAL LAPAROTOMY 69

Cattell and
Braasch
maneuver

Duodenum

Figure 62 The maneuver developed by

Cattell and Braasch for right medial visceral
rotation takes advantage of the avascular right
colonic gutter in mobilizing the colon so that Inferior
vena cava
the surgeon might inspect the retroperitoneal
structures behind it. Abdominal aorta

Stomach
Maddox Spleen
maneuver

Figure 63 The Maddox maneuver takes advantage of the

avascularity of the left colonic gutter to rotate the left colon
medially to allow inspection of the retroperitoneum on the left
side of the abdomen.

Figure 64 The difference in

suture placement between indi-
vidual closure of the fascial layers
and mass closure in a midline
incision.
 70 SECTION I: GENERAL CONSIDERATIONS
incisions. Examples are the right subcostal (Kocher) inci-
sion for open cholecystectomy and duodenal exploration,
the muscle-splitting RLQ incision for appendectomy, and
the Pfannenstiel incision for nonmalignant gynecologic
pathology.
Incorrect Choice of the Kocher Incision
Consequence
In some circumstances, the right subcostal incision is
insufcient to complete a gastrectomy, to adequately
explore the duodenum, or to evaluate unsuspected
pelvic pathology.
Repair
The Kocher incision is the easiest of the three specialty
incisions to modify, in that it can be easily extended
transversely in either direction because fascia and muscle
have been divided in the same direction as the skin.
Prevention
Choose a midline incision if pelvic pathology is
expected. Upper abdominal pathology can usually be
exposed after extension of a Kocher incision.
Incorrect Choice of the Muscle-Splitting
Appendectomy Incision
Consequence
If the diagnosis of appendicitis is incorrect or if the
appendix cannot be delivered through an RLQ muscle-
splitting incision, that incision cannot be extended in
its original form because it is made by separating the
bers of the external oblique, internal oblique, and
transversalis muscles in three different directions.
Because of the orientation of these muscles, their sepa-
ration forms a keyhole incision with limited exposure
beyond McBurneys point.
Repair
Extension of the muscle-splitting appendectomy inci-
sion to permit additional exploration requires the
medial end of the incisions in the two oblique muscles
to change direction slightly as the extension is devel-
oped transversely across the rectus sheaths. In some
instances, it is possible to spare the rectus muscle itself
when extending the incision in this manner (Fig. 65).
However, if more incision is required, the incision may
be extended as far to the left as is necessary, thereby
permitting access to the entire abdomen.
Prevention
Whereas exploration for pathologically normal appen-
dices still occurs, the limitations to further exploration
that this incision imposes should be able to be miti-
gated by heavier reliance on preoperative imaging. In
equivocal cases, a laparoscopic approach or midline
incision should be chosen over the muscle-splitting
RLQ incision.
Incorrect Choice of the Pfannenstiel Incision
Consequence
Use of the Pfannenstiel incision, which marries a cos-
metically acceptable low transverse abdominal incision
with a vertical midline fascial incision, also presumes
that the scope of the pathology has been accurately
assessed prior to surgery. If more exposure is required
because this is not so, the surgeons ability to make the
incision larger is limited. Even extensive extension of
both skin and fascial incisions in their original direc-
tions does not achieve more exposure because the inci-
sions are made at 90 to each other (Fig. 66).
Repair
Extend the transverse skin incision rst, and in both
directions. Should this not afford the opportunity to
extend the fascial incision in a cephalad direction, an
inverted T skin incision will have to be accepted, as the
midline fascia and its overlying skin are incised cephalad
to accommodate the exposure.
Prevention
Abdominal imaging or laparoscopic evaluation may
help decide whether a Pfannenstiel, a midline laparot-
omy, or a laparoscopic/laparoscopy-assisted approach
is most appropriate.
Failure to Consider the Consequences of an
Incisions Innervation and Blood Supply
Consequence
When making a new incision parallel to another recent
laparotomy incision, the surgeon should consider the
possibilities that the intervening abdominal walls vas-
culature will be compromised or that denervation injury
will result. This is less true if the second incision is made
many years after the rst. Even without prior incision,
subcostal or chevron incisions, which divide the
obliquely coursing intercostal nerve branches, may
result not only in sensory deprivation to the area infe-
rior to the scar but in postoperative lower abdominal
denervation atrophy and laxity as well. The problem is
worse when such incisions are bilateral (Fig. 67).
Repair
Denervated muscle atrophies. Attention to the bulk and
the bleeding from the musculature at the time of the
second incision may dictate the width of fascial closure
bites, particularly when a midline incision follows
a paramedian incision. In most other circumstances,
choice of a midline incision for a second operation is
safe. Denervation laxity from subcostal or chevron inci-
sions occurs sporadically and cannot be repaired. The
 6 GENERAL LAPAROTOMY 71

External
oblique
incision

Internal
oblique
incision

Original Rectus-
incisions sparing
extension

Original Rectus-
incisions sparing
Transversus
extension
abdominis
incision

Figure 65 The muscle-splitting appendectomy incision is notoriously strong and seldom develops a hernia because the three lateral
musclesexternal oblique, internal oblique, and transversalisare opened in different directions. When operative ndings dictate that this
incision be enlarged, however, the direction of the muscular incision in the external oblique and internal oblique musculatures must be
altered slightly as the incision is extended medially across the rectus sheaths. If only a small extension is required, the rectus muscle itself
may be able to be spared and retracted medially as the anterior and posterior sheaths are incised. Full-thickness retraction of the three
muscle layers with vectors of force at 90 to the axis of intended extension will facilitate the alignment of the three layers as medial exten-
sion proceeds.

best the surgeon can do is not to mistake the laxity for
an abdominal wall hernia, which it is not.
Prevention
Attention should be paid to previous abdominal
incisions and to a contemplated incisions direction,
position, vasculature, and innervation before the inci-
sion is made.
Failure to Anticipate Malignant or Nonmalignant
Adhesions when Making the Abdominal Incision
An abdominal scar should alert the surgeon to the poten-
tial for intra-abdominal adhesions caused iatrogenically or
in response to the original pathology. The abdominal
surgeon should be aware of any existing muscular defect
in an area of intended incision as well as whether pros-
thetic mesh has been previously placed to repair a defect
of the abdominal wall. Adhesion of the viscera to the
abdominal wall in these circumstances, and in the case of
tumors close to the anterior abdominal wall, should be
presumed.
Consequence
Visceral injury or compromise of en-bloc resection of
tumor may occur if the surgeon does not correctly
anticipate the position of the viscera, the adhesions, and
the tumor.
Repair
See the section on Injury to the Intestine, below.
Prevention
An unrepaired hernia increases the likelihood of visceral
injury as the abdominal incision is developed beneath
the dermis, whereas the presence of prosthetic mesh in
an operative eld substantially increases the likelihood
 72 SECTION I: GENERAL CONSIDERATIONS
External
oblique m.
Rectus
sheath
Skin and
fascial incision
Figure 66 In the case of the Pfannenstiel incision, the cosmetically desirable low transverse skin incision is placed at right angles to the
midline fascial incision. Whereas the skin incision may be lengthened to accommodate upward extension of the fascial incision, at some
point, it may have to be abandoned or converted to an inverted T incision to accommodate the disparity in directions. For this reason,
specialty incisions should be selected only when the pathology is well-dened preoperatively.
Superior
epigastric a.
Rectus
abdominis m.
Inferior
epigastric a.
that the abdominal viscera will be adherent to the ante-
rior abdominal wall in the region of the repair. In the
case of suspected matting of the intestine due to inam-
mation, tumor, or previous abdominal surgery, an
effort should be made to enter the peritoneal cavity well
away from the site of the pathology. Incision selection
and the choice to lengthen a previous incision have as
their goal exposure of a previously inviolate area of
fascia and peritoneum for atraumatic entry into the
abdomen. As with reuse of a previous laparotomy inci-
sion, in hernia patients, the initiation of a subsequent
incision well away from the visceral bulge or the origi-
nal repair will often permit entry into the abdomen
through an unscarred region and allow identication
of structures to be preserved. Thus, beyond the goal of
Rectus
sheath
Rectus
abdominis
Vertical incision Extension of
skin and anterior
sheath incision
Subcostal
incision
Anterior
cutaneous Figure 67 The intercostal nerves course obliquely
nerve of
subcostal in the abdominal wall, as shown. Thus, upper abdominal
nerves incisions traversing multiple nerve levels cause sensory
and motor deprivation to the skin and muscles inferior
to the incision. When the incision is bilateral, the dener-
vation atrophy of the lower abdominal musculature may
result in an undesirable loss of muscle tone. A bulge may
occur without overt herniation.
optimal exposure of the intra-abdominal pathology,
incisional planning seeks to ensure that surgical entry
is volitionally made into the peritoneal cavity itself
rather than erroneously made into the lumen of a
hollow viscus or the capsule of a solid organ.
Small incisions reduce, and may compromise, exposure.
In the case of malignancy, a longer incision may preserve
the opportunity for en-bloc resection. Incisional planning
for removal of large tumors or the extirpation of patho-
logically enlarged organs can be facilitated by abdominal
palpation after anesthetic agents have relaxed the abdom-
inal wall, thereby avoiding incision directly into the tumor
or its parietal peritoneal attachments. The surgeon should
not forego this one last opportunity for the physical exam-
ination to inform incisional planning.

Failure to Identify the Peritoneal Cavity
Consequence
Mistaking the wall of a viscus for a point at which the
peritoneum permits atraumatic entry may result in vis-
ceral injury.
Repair
See the section on Injury to the Intestine, below.
Prevention
Unless a hernia is present, the muscular fascia of the
abdominal wall is seen before the peritoneum, thereby
ensuring that the peritoneal cavity will be prospectively
identied and opened in a controlled fashion. Although
identifying the abdominal midline may seem an intui-
tive quest, incisions intended for the linea alba are often
made off midline, causing the surgeon to unnecessarily
enter the rectus sheath and compromise bloodless entry
into the peritoneal cavity. The surgeon knows that the
anterior rectus sheath has been mistaken for the linea
alba when the rectus muscle and its sheaths are visible
as separate layers, because true midline incisions do not
expose the red muscle bellies of the rectus abdominis
muscles before encountering properitoneal fat. The
midline may be identied in obese patients by basing
one end of a midline incision at the umbilicus or xiphoid
or by having both operator and rst assistant simultane-
ously apply lateral traction after the skin incision is
made. The subcutaneous tissue will part and identify
the abdominal midline by exposing the cross-hatching
of the subcutaneous fat (Fig. 68). In more lateral inci-
Subcutaneous fat
Crosshatching of subcutaneous
fat overlies linea alba
Figure 68 Lateral traction of the divided skin and supercial
subcutaneous fat in obese subjects allows identication of the
midline through observation of the midline subcutaneous fat, whose
cross-hatching strands identify the linea alba.
6 GENERAL LAPAROTOMY 73
sions, the rectus, oblique, and transversalis muscles and
their fasciae are sequentially and identiably divided
before the peritoneum is exposed.
Independent of the choice or direction of incision, the
anterior surface of the parietal peritoneum is often fused
to the deepest layer of fascia. Thus, the safest entry into
the peritoneal cavity is with a knife. The surgeon and rst
assistant should elevate the peritoneum with toothed
forceps; peritoneal entry is made with the belly of a No.
10 blade. Although compelling reasons of hemostasis,
economy of time, and surgeon experience might suggest
division of the muscle layers with the electrocautery, with
rare exception, the initial entry into the peritoneal cavity
should be made with cold steel. Even the unfortunate
surgeon who nds that an incision intended only for the
peritoneum has also entered a loop of intestine will be
gratied at the time of repair that she or he has cleanly
incised, rather than burned or spread, her or his way into
the intestine.
Once a small entry has been made into the peritoneal
cavity, the operating surgeon should insert his or her
nger and palpate the parietal peritoneum in the direction
of intended incisional extension, in order to see whether
the incision may be atraumatically developed in that direc-
tion. If free of adhesions, the incision can then be enlarged
with the electrocautery, dividing all layers of the abdomi-
nal wall simultaneously rather than in sequence. In the
case of previous laparotomy, hernia, inamed abdominal
viscera, enterocutaneous stula, or adherent tumor, the
laparotomy incision should be developed under direct
vision and only as far as the rst intraperitoneal adhesion.
At this point, Kocher clamps should be placed to elevate
the fascial edges of both sides of the incision so that loops
of bowel adherent to it might be visualized. For initial
dissection, after careful fascial division, an area is typically
chosen in which the adhesions are translucent because a
pocket of air or uid has collected beneath them and their
associated loops of intestine, signaling the absence of
other viscera at risk beyond them. Translucent adhesions
may be taken down sharply, and the free abdominal cavity
may be thus visualized and entered (Fig. 69). For the
same reason that spreading with the scissors is not desir-
able in entering the peritoneal cavity, minimal spreading
is often best in the early development of the laparotomy.
With traction provided by Kocher clamps in the vertical
direction, the operating surgeon can often, with the aid
of a Mikulicz pad held by the clawed nondominant
hand, apply atraumatic tangential traction to the adhered
loop of bowel, thereby permitting identication of inter-
loop adhesions or adhesions of bowel to abdominal wall.
The adhesions are maximally exposed and lengthened by
this maneuver, and lysis can occur with sharp dissection
as the ngers of the surgeons nondominant hand
subsequently shift into the free space thus created
(Fig. 610).
Lysis of adhesions is a shared and dynamic responsibil-
ity between the operating surgeon (often positioned on
 74 SECTION I: GENERAL CONSIDERATIONS
90
0 free the entire underside of the parietal peritoneum and
45
Figure 69 Kocher clamps applied to the divided fascia of a
wound should be retracted at 90 to the body; the nondominant
hand of the operating surgeon should be fanned over a Mikulicz
pad; and gentle traction should be applied tangentially. The adhe-
sions will thus be maximally lengthened and exposed under con-
trolled tension, with less likelihood of traumatizing the bowel.
Figure 610 The rst assistant presents adhesions to the oper-
ating surgeon in such a way that there is a curtain rather than a
tent of bowel as the operating surgeon applies tension. In this
manner, avoidance of a traction tear on the apex of the tent or
accidental amputation of the bowel when lysing pointed adhesions
will not occur.
the patients right and lysing adhesions to the left of
midline) and the rst assistant (often positioned on the
patients left and lysing adhesions to the right of midline).
Assuming right-handed dominance and these positions at
the operating table, the operating surgeon is best posi-
tioned to lyse adhesions in the epigastric midline and the
rst assistant is optimally positioned to lyse adhesions in
the pelvis. For this reason, in pelvic operations, the surgeon
stands on the patients left side. Although it is tempting
to identify and chase interloop adhesions deep into the
peritoneal cavity, a focused determination and a synergis-
tic cooperative strategy should be formulated between
rst assistant and operating surgeon to rst identify and
to develop the entire length of the contemplated abdom-
inal wall incision before deeper intra-abdominal pathology
is addressed.
Injury to the Intestine
Consequence
Visceral leak, abscess, stula, sepsis, shock, or death
may occur, depending on the time of discovery of the
visceral injury, the amount of soilage incurred, the
resistance of the host, and the success of the repair.
Repair
Injury to the intestine usually occurs while freeing it
from either the abdominal wall or an adjacent viscus.
Management of an iatrogenic injury depends on oper-
ative circumstances, whether the injury is to the large
or the small intestine, whether a bowel preparation has
preceded surgery, and whether the injury is full thick-
ness or partial thickness.
Partial-thickness injuries usually need not be repaired.
However, in the presence of severe adhesive disease, prior
radiation, hematoma, or other comorbidity compromising
repair, the relative paucity of a normal blood supply may
cause a partial-thickness injury to evolve to a full-thickness
injury in the postoperative period.
When a loop of bowel is injured, it is tempting to react
immediately by attempting to place sutures or Babcock or
Allis clamps to stem the ow of enteric contents. However,
even atraumatic clamping of a partially dened enterot-
omy often helps very little and sometimes induces further
trauma. Rather than close the enterotomy in an adhered
loop of bowel in situ, the loop should be freed from adja-
cent structures, mobilized for complete inspection, and
assessed for its salvage potential. Mobilization may dem-
onstrate signicant bowel injury or devascularization. A
temporizing damage control approach, with temporary
suture or stapling of the bowel, or division of the bowel
with subsequent reassessment, may well be appropriate,
but only after mobilization. To commit to denitive
repair, resection, and/or anastomosis at the time of injury,
before mobilization, or before the goals of the operation
have been achieved has the potential to waste time; the
initial closure may be inadequate or multiple injuries in
the same short segment of bowel may be identied and
need to be handled by incorporation of several injuries
into a single resection.
Full-thickness small bowel injuries are handled differ-
ently than full-thickness large bowel injuries. In general,
independent of whether the bowel has had mechanical or

antibiotic preparation, most small bowel injuries may be
handled with simple repair or resection and repair with
anastomosis; uncomplicated full-thickness large bowel
injuries in unprepared intestine should, generally, be
handled with simple repair if they are solitary and if
minimal fecal contamination has occurred. When possible,
intestinal injuries should be closed transversely to mini-
mize the likelihood that the repair would hourglass or
narrow the caliber of the involved viscus. The Heineke-
Mikulicz pyloroplasty6 gives good evidence that even
when a rent is absolutely and deliberately longitudinal,
most enterotomies can be closed transversely.
If resection is required for extensive large bowel injury
in circumstances in which there has been no bowel prep-
aration, consideration should be given to exteriorizing the
ends of the bowel, with reanastomosis at a subsequent
surgery. Primary closure of a large bowel injury becomes
more and more indefensible when the patient is ill; the
operation is extensive; the injuries are unexpected, mul-
tiple, or substantial; or compromise of a prosthetic device
by failed closure is possible. Permanent prosthetic devices
such as nonabsorbable mesh should generally not be elec-
tively placed in the setting of enteric injury.
Whereas patient, unhurried dissection along the
antimesenteric surface of the small intestine is often suc-
cessful in freeing even the densest of adhesions, in some
circumstances, it becomes abundantly clear that a loop of
small intestine diving into the pelvis will not be able to be
freed under direct visualization. In operations for intesti-
nal obstruction, this situation is heralded by a dilated loop
diving into the pelvis adjacent to an unobstructed loop
coming out of the pelvis. When this circumstance exists,
and when injury to such bowel in freeing it is judged to
be inevitable, the appropriate goal is to expeditiously
resect as short a segment of intestine as is possible, while
preserving and minimizing injury to the structures to
which the involved loop is adhered. To commit to the
tedious freeing of such a loop in the hope of salvaging it
is a fools errand; it often proves to not be possible, and
the futile attempt wastes a signicant amount of operating
time. When small bowel resection is judged to be inevi-
table in adhesive disease, the aficted loop should be
delivered into the upper abdomen by the least traumatic
means possible, and an assessment should then be made
as to whether repair or resection with anastomosis is most
appropriate. When the aficted loop is attached to tumor
and en-bloc resection is contemplated, the loop adherent
to the tumor is isolated and left in situ for future mobili-
zation with the specimen, and fecal continuity is restored
by anastomosis of the two functioning ends of the bowel
thus freed from the tumor.
Prevention
Only after the incision has been extended to the desired
length is a directed approach to the pathology under-
taken with adhesiolysis. In so doing, the bowel should
be minimally instrumented with grasping forceps or
6 GENERAL LAPAROTOMY 75
Figure 611 Once a translucent area in the adhesive curtain is
identied and developed, the index nger of the nondominant hand
can be hooked around the remaining adherent loops of bowel,
and they can be freed. The operators nondominant index behind
the bowel both provides traction and ensures the operating surgeon
that additional loops of bowel are not adherent.
other traumatic instruments, as tangential traction with
cotton pads or presentation of the bowel by elevating
it manually often provides sufcient retraction to allow
visualization of intervisceral adhesions. As lysis pro-
gresses, an effort should be made to repetitively identify
and selectively work at the antimesenteric surface of
adhesions to minimize the chance of compromising the
bowels blood supply. The assistant should present
adhesions as a broad band attaching bowel to adjacent
viscus or abdominal wall, rather than tenting them in
a manner that invites enterotomy (Figs. 610 and 6
11). Use of the electrocautery should be avoided, as
should large spreads of the scissors or grasping of the
intestine with surgical instruments. Most adhesions can
be progressively exposed and lysed as small incisions are
made with the scissors without spreading. The site
chosen for incision develops dynamically as exposure
unfolds; in lieu of scissor use, some prefer sharp adhe-
siolysis with the No. 10 blade.
Adhesiolysis with the No. 10 blade should not be
attempted by the novice surgeon because it requires a
delicate touch and considerable experience with the
texture and spectrum of abdominal adhesions. Frequent
blade changes are necessary for effective use of the tech-
nique because it is the knifes tip, rather than its belly, that
incises the adhesion. The tip of the blade should be placed
at the position of intended initiation of the adhesiolysis
and rotated counterclockwise to form a large acute angle
with the intended direction of incision. The knife should
then be dragged to the right, maintaining this acute angle
as the adhesion is lysed. The largest acute angle of blade
 76 SECTION I: GENERAL CONSIDERATIONS
A Prevention
B or previous stomal creation, the potential for visceral
C is vacated after repair, incorporating an overlying ellipse
Figure 612 A and B, In lysis of adhesions using a scalpel, the
tip of the No. 10 blade engages the adhesion. The largest acute angle
that will allow the knife to cut while being dragged in the intended
direction of the lysis is chosen. C, Smaller acute angles risk injury
to the bowel.
with trajectory permitting the knife to be moved in the
intended direction should be chosen and maintained as
the blade is moved (Fig. 612). Smaller angles will increase
the likelihood of bowel injury.
Lysis of adhesions is among the most sophisticated tasks
performed by the abdominal surgeon, and no precon-
ceived time should be allotted for its completion. Exten-
sive adhesions demand extensive patience and meticulous
dissection. When dense adhesions are anticipated, no
competing commitments on the surgeons time should be
made. When adhesions are encountered unexpectedly in
the course of dissection, arrangements should be made for
all competing commitments to be rescheduled to mini-
mize the risk of bowel injury. The rst assistant should
provide the operating surgeon with as panoramic a view
as the anatomic situation permits. Success is often less the
result of heroic traction than of an assessment as to how
the bowel can be manipulated to best display the desired
incisional plane.
Visceral Injury during Exposure of a Ventral
Hernia Defect
Consequence
The operative plan for elective repair of ventral hernia
often presupposes the placement of prosthetic mesh
under aseptic conditions. Visceral injury compromises
the bacteriologic environment of the wound.
Repair
Injury to bowel may preclude prosthetic repair, neces-
sitating primary closure or abandonment of repair
altogether.
Even in the setting of previous laparotomy, in patients
with an intact abdominal wall, the surgeons potential
to injure the abdominal viscera is at least theoretically
limited by the necessity to traverse the fascia before the
viscera are encountered. When those viscera lie in the
subcutaneous tissue, as is the case with ventral hernia
injury is enhanced.
The techniques for safe subsequent laparotomy, as
described previously, may be adapted to permit denition
and exposure of ventral hernias. An incision is begun at
some distance from the palpable hernia sac in order to
avoid entry into a peritoneal sac apposed to the skin. As
the hernia occupies space in the subcutaneous tissue that
of skin at the beginning of the operation serves three
useful purposes. The maneuver minimizes the time-
consuming need for dissection of the sac from the overly-
ing and often attenuated skin, which is often subsequently
discarded. Improved visibility created by wider exposure
enhances the surgeons ability to dene the sacs interface
with the fascia and to avoid visceral injury. Finally, resec-
tion of redundant skin and subcutaneous tissue acknowl-
edges the new geometry of the wound and the absence
of a visceral bulge after fascial repair, thereby minimizing
the magnitude of the skin aps and making seroma forma-
tion less likely.
In either mobilizing a hernia sac or identifying the
serosal surface of an externalized viscus during stomal
reversal, blunt dissection is the surgeons friend. For
ventral hernias, the sac is exposed after careful incision of
the skin and subcutaneous tissue. The gloved hand invag-
inated into a Mikulicz pad strips the subcutaneous fat
away from the sac to allow visualization of the sacs origin
at the disrupted fascia of the abdominal wall. Three
approaches to safe repair are possible. For hernias in which
incarceration is not suspected, some surgeons prefer to
bluntly develop the plane between the abdominal walls
musculature and the sacs parietal peritoneum without
ever entering the peritoneal cavity. They then close the
muscular wall extraperitoneally. Other surgeons prefer to
identify a point in the sac at which the viscera are not
believed to be adherent to the peritoneum. They open the
sac in that region, dissect the omentum or hollow viscus
away from the parietal peritoneum, resect the sac, and
then close the defect. A third option is to open the peri-
toneum only after circumferential identication of the
sacs interface with the fascial ring is complete (Fig. 613).
In the latter two instances, safe entry into the peritoneal
cavity is pursued with adhesiolysis as described previously
for recurrent laparotomy.
 6 GENERAL LAPAROTOMY 77

Peritoneum
Muscle Skin

Subfascial plane

or

Subfascial Peritoneum Prosthetic

A B plane mesh

C D

Fat Skin

or

Subfascial Peritoneum Prosthetic

E plane mesh
Figure 613 A, After skin incision and exposure of the fascia of the abdominal wall, denition of the ventral hernia sac is achieved by
blunt dissection in the subcutaneous space with a Mikulicz pad. B, Keeping the peritoneum of a broad-based hernia sac intact, a subfascial
plane is developed to allow primary closure of the musculofascial defect or the attachment of prosthetic mesh. This technique is not suit-
able for situations in which incarceration is suspected or for narrow-necked hernia sacs. C, Some surgeons enter the sac in an area where
the viscera are not believed to be adherent before the sac is fully exposed to the level of its interface with the fascia of the abdominal
wall. D, Alternatively, the sac is completely exposed, and the surgeon enters at its interface with the fascial ring. E, Repair of the fascia is
accomplished with either primary closure or subfascial implantation of prosthetic mesh circumferentially anchored to healthy fascia.

Visceral Injury during Dissection of

an Intestinal Stoma
Consequence
Often, stomal closures can be effected without opening
the counterincision made to create them by dissecting
circumferentially about the stoma itself and preserving
as much of the functioning intestine as possible. Injury
to the bowel, compromise of its blood supply, or incor-
poration of an unrecognized bowel injury into a stomal
closure can result in enteric leak and the failure of
stomal closure. Recognized injury may require exten-
sion of the laparotomy to resect or expose more intes-
tine to ensure that two viable ends of bowel are available
for reanastomosis.
 78 SECTION I: GENERAL CONSIDERATIONS

Repair
Once the bowel is injured during dissection of a stoma,
repair is ill advised; exposure and mobilization of an
undamaged segment of intestine are preferable.

Prevention
A blunt dissection technique specic to separation of
the subcutaneous tissue from the serosa of a stoma was
rst demonstrated to me by Hechtman (personal com-
munication, Brigham & Womens Hospital, Boston,
1983). The stoma is sharply circumscribed with a full-
thickness scalpel incision made at a distance of no more
than 1 mm from the mucocutaneous junction. This
peristomal incision is then developed sharply into
the subcutaneous tissue circumferentially until fat is
exposed. Then, using the heel of the knife handle
typi-cally used to carry a No. 10 blade, the serosal
surface of the viscus is gently stroked in the direction
of the fascia. This maneuver allows for identication
and sharp lysis of any remaining dermal adhesions and
clear visualization of the subcutaneous viscus and its
interface with fascia. As the maneuver is circumferen-
tially pursued, it is usually possible to identify a point
at which the externalized viscus can be readily separated
from the abdominal wall musculature and from which
the circumferential separation of stoma from abdomi- Figure 614 Hechtmans technique for separation of the subcu-
nal wall can proceed without either enterotomy or loss taneous tissue from the serosa of an externalized loop of intestine.
of bowel length. As with hernia repair or the identica- The stoma is circumscribed a millimeter away from the mucocuta-
tion of the distal end of a Hartmann colostomy, the neous junction. The heel of the knife blade is utilized to bring the
maneuver may be coupled with enlargement of the adherent subcutaneous fat away from the serosal surface of the
bowel, leading the surgeon to the fascial ring. A point of the fascial
original stomal incision, abdominal counterincision, or
ring usually becomes apparent where the bowel can readily be freed
both. Loop stomas may often be fully dissected without
from it. This point is utilized as the entrance point for circumscrip-
a counterincision when dissection is performed with tion of the bowel, freeing it from fascia without enterotomy and
the knife handle as described (Fig. 614). The millime- without loss of length.
ter of circumferential skin is easily removed from
the bowels serosal surface once the stoma has been
mobilized. hemostasis. However, if the injury is near a hollow
viscus, use of the electrocautery is unsafe because of
energy scatter; the hollow organ in jeopardy should be
Liver Injury
sharply dissected free of the liver before the electrocau-
Consequence tery is used near it. Rarely, mattress sutures are needed
Unexpected injury to the liver at laparotomy most to obtain hemostasis of an avulsed liver edge.
often occurs because of failure to appreciate an attach-
ment of its capsular surface to the anterior abdominal Prevention
wall. Under such circumstances, retraction of the Injury can be avoided by a diligent focus of both
abdominal wall avulses the capsule, thereby stripping it surgeon and assistants on the parietal peritoneal surface
and inciting bleeding. as laparotomy is extended over the capsular surface of
the liver. Properly managed, sharp dissection allows the
Repair liver to drop away as the parietal peritoneum overlying
Iatrogenic rents are usually less than 1 cm in depth and it is separated from Glissons capsule.
are often insufcient to produce life-threatening hepatic
hemorrhage. However, such injuries can be an annoy-
Splenic Injury and Avoidance of Misadventure
ing source of constant oozing during the operation and
in the Lesser Sac
may compromise exposure of the intended operative
eld. Should the liver be injured over its dome, the Consequence
combination of pressure and electrocautery or use of Bleeding, splenic repair or removal, pancreatic injury,
the Argon beam device is often sufcient to obtain and pancreatic stula may occur as short-term conse-

quences. Immunocompromise and increased suscepti-
bility to infection with encapsulated bacteria may
subsequently result in splenectomized patients.
Repair
Should the spleen be damaged because of excess trac-
tion on the stomach or colon, the injury often responds
to packing. As with the liver, electrocautery may be
selectively used if all hollow viscera are free of the
spleen. Mattress sutures are less successful in securing
hemostasis in splenic injury than in controlling super-
cial hepatic bleeding. The spleen should be delivered
into the midline for such repairs, following lysis of its
diaphragmatic attachments. Excessive trauma to the
convexity of the splenic capsule in doing so can be
avoided by dissecting the diaphragm free of the spleen
as the latter is gently retracted medially. When splenic
injury is combined with bowel injury or results in hem-
orrhage that is difcult to control, splenectomy is often
the best choice. If splenectomy is chosen, care should
be taken on ligature of the hilar vessels to avoid injury
to the pancreatic tail, which resides in the splenic hilum.
Should injury to the tail be noted, suture repair of the
pancreas should occur. A drain should be placed in the
area to facilitate the management of enzyme-rich pan-
creatic drainage should the repair fail. Uncomplicated
splenectomies or splenic injuries that are repaired
without pancreatic injury, however, should not be
drained.7
As the need to remove spleens for trauma or hemato-
logic disease has diminished, iatrogenic injury has become
the chief reason for splenectomy. Splenic injury most
often occurs in elective surgery by triangulation of its
diaphragmatic attachments and the application of exces-
sive traction to either the stomach or the splenic exure
of the colon as these are manipulated for left upper quad-
rant surgeries (Fig. 615).
Prevention
Incision planning for safe entry into both the abdomen
and the lesser sac has a role in avoiding splenic injury.
When the greater curvature of the stomach is mobilized
for gastric operations or elective splenectomy, the lap-
arotomy incision should be made in either the left
subcostal or the midline position in a way that allows
gastric retraction and facilitates visualization of the
spleen and its hilum. The surgeon should recognize
that the middle colic artery and right gastroepiploic
artery are closest to each other in the abdominal midline
and that a residual veil of embryologic mesogastrium
puts both vessels at risk for unintended injury in the
approach to either. To avoid the injury, initial entry
into the lesser sac should be near the midportion of the
stomachs greater curvature, where the right gastro-
epiploic artery becomes attenuated and the gastrocolic
omentum can be readily traversed quite far to the left
of midline and well away from the origin of the middle
6 GENERAL LAPAROTOMY 79
Stomach
GSL
SRL
PSL
SCL
Phrenocolic lig.
Pancreas Diaphragm
Colon
Figure 615 The tethering of the spleen to the diaphragm,
stomach, and splenic exure of the colon in the left upper quadrant
is the anatomic determinant for splenic injury with traction on the
colon or stomach.
colic artery. Gentle caudal traction of the transverse
colon by the assistant, combined with anterior traction
of the stomach by the surgeon, will often identify a
translucent area in this region of the gastrocolonic
omentum into which atraumatic entry into the lesser
sac can be made without vascular injury (Fig. 616).
Anesthesia personnel should assist the surgeon. A sur-
prising number place the nasogastric tube as an ornamen-
tal device only; judicious suction on a well-placed tube
facilitates the surgeons atraumatic traction on the stomach
and facilitates lesser sac entry and visualization of the
splenic hilum.
For elective gastric surgery or splenectomy, there is no
need to mobilize or deliver the diaphragmatic (convex)
surface of the spleen early in the dissection. Rather, the
short gastric vessels should be identied and ligated in situ
and under direct vision, with purchases of sufcient size
to allow vascular pedicle ligation well away from the gastric
wall. Postoperative necrotic perforations of the gastric
wall, as reported in the older gastrectomy literature, are
more likely full-thickness clamp or ligature injuries than
devascularization associated with vessels ligated at appro-
priate distances along the greater curvature. The process
of freeing the stomach from the spleen is facilitated not
only by suction on the nasogastric tube but also by the
gentle lateral pressure of the extensor surface of the rst
assistants cupped left hand exerted against the gastric
remnant as the operating surgeon places the deep ties. The
linear stapling device used for laparoscopic surgery allows
the uppermost short gastric vessels to be identied and
secured with good visualization and minimal gastric retrac-
 80 SECTION I: GENERAL CONSIDERATIONS

R. gastroepiploic
artery

Enter lesser sac

through mesocolon
(lesser sac)

LATERAL LATERAL
Anterior Posterior Anterior Posterior

Stomach

Right
Duodenum gastro- Aorta
Right
gastro- epiploic
epiploic artery
artery
c
sa

Gastro-colic Gastro-colic
ac

r
rs se
omentum se omentum Les
Les
Transverse Transverse Figure 616 Entry into the
colon Middle colon Transverse lesser sac near the midportion of
colic artery mesocolon the greater curvature to the left
of midline places the surgeon
well away from the origins of the
right gastroepiploic and middle
Greater Small
intestine colic arteries, thereby avoiding
omentum
vascular injury to the transverse
mesocolon.

tion, avoiding undue tension and avulsion of the dia-
phragmatic aspect of the spleens capsule (Fig. 617).
The inferior pole of the spleen is often injured with
excessive medial retraction of the splenic exure of the
colon during its mobilization for colonic resection or left-
sided retroperitoneal exposure. Two maneuvers decrease
the likelihood of this event. The lower pole of the spleen
can be exposed in a controlled manner, and injury to it
avoided, if the colon dissection is begun by entering the
lesser sac through the gastrocolic omentum at the midpor-
tion of the greater curvature and proceeding to the
patients left to join a separate incision made along the
white line of Toldt. This second incision, in turn, is initi-
ated at a convenient spot lateral to the descending colon
and is developed superiorly under direct vision until the
operator approaches the lower pole of the spleen. By
periodically and gently lifting the omentum in the region
of the splenic exure, and concurrently following the
colon retrograde from the point of incisional initiation in
the white line of Toldt, the course of the colon at the
exure and the position of the spleen can be inferred and
the two incisions can be joined. This joining of the lateral
aspect of the incision in the gastrocolic omentum with the
superior aspect of the incision in the white line of Toldt
allows for mobilization of the splenic exure under direct
vision in a way that does not put tension on the splenic
capsule or cause its avulsion. A common error made in
making or connecting these incisions is to impatiently and

Lesser
sac
Figure 617 Utilizing the exposure provided by
the combination of a functioning nasogastric tube and
extension of the rst assistants wrist. The cupped
left hand of the assistant against the stomach wall
allows working space for the surgeon if a cupped
hand exerts gentle pressure. The endoscopic linear
stapler is shown securing the superiormost short
gastric vascular pedicle.
imprudently lift up on the splenic exure during the dis-
section, thereby bringing the colon and its lienocolic
ligaments forward, but leaving the spleen itself attached
posteriorally to the diaphragm. This erroneous maneuver
seldom improves visibility, and it is often difcult to judge
and nely control the tension placed on the spleen when
pulling on the colon in this way. The splenic capsule, as
the entity least able to resist these forces, tears. The pre-
ferred alternative is for the operator to push down on the
splenic exure with a laparotomy pad as the exure is
approached, to gently ex the ngers of the nondominant
hand, and to exert tangential traction medially (not ante-
riorally) as the incision in the line of Toldt is joined to the
one dividing the gastrocolic omentum and exposing the
lesser sac (Fig. 618). Sometimes, the lienocolic adhesions
are exceptionally robust and need to be divided between
clamps or clips. Under most circumstances, however, they
can be simply divided with the electrocautery or the scis-
sors under direct vision.
Injury to the Esophagus
Consequence
Sepsis, intra-abdominal contamination, subsequent
operation, shock, or death may occur, depending on
the time of recognition of the injury and the success of
the repair.
6 GENERAL LAPAROTOMY 81
Nasogastric
tube
Spleen
Stomach
Endoscopic
GIA
Repair
Should the esophagus be erroneously entered while
encircling it bluntly, the organ can usually be rotated to
allow the placement of interrupted nonabsorbable
sutures. Most authors would reinforce such a closure with
a fundoplication, performed in much the same manner
as an elective Nissen for reux disease (Fig. 619).8
Prevention
Injury to the esophagus most often occurs when a well-
described and crucial rst step in its mobilization is
omitted. After the peritoneal and diaphragmatic attach-
ments of the left lobe of the liver have been divided to
expose the esophageal hiatus, this rst maneuver is to
sharply and transversely incise the peritoneum overly-
ing the distal esophagus from the angle of His on the
patients left side to the junction of the stomachs lesser
curvature with the esophagus on the patients right. It
is only then that the esophagus can be properly mobi-
lized and atraumatically encircled. The right index
nger of the operating surgeon is inserted into the
mediastinum superior to the angle of His and encircles
the esophagus, with great care taken to appreciate the
full circumference of the esophagus and the easily pal-
pable groove between this organ and the aorta. Bleed-
ing from high lesser curvature vessels occurs with a
transverse trajectory of the circumscribing nger and is
 82 SECTION I: GENERAL CONSIDERATIONS
Spleen
Incision in
gastrocolic
omentum
Incision in
line of Toldt
Colon
avoided when the circumscribing nger makes an
obtuse angle pointing from the angle of His to the
patients right shoulder.
Injury to the Ureter
Consequence
Urinoma may accumulate and subsequent surgery may
be necessary if an injury is not recognized or if adequate
repair of a ureteral injury is not achieved.
Repair
The blood supply to a ureter ramies proximally from
branches of its ipsilateral hypogastric artery. If the prox-
imal ureter is injured and not devascularized and the
remaining ureter can be readily identied, the injury
can often be repaired over a stent placed either cysto-
scopically or through a cystotomy. In the latter case,
the bladder should be closed in multiple absorbable
layers and decompressed postoperatively with a Foley
catheter. All repairs of ureters or bladder should be
drained. Extensive injuries or injuries associated with
devascularization of the ureter demand urologic con-
sultation because they may require mobilization of the
kidney, interposition of a loop of bowel, hitch mobi-
lization of the bladder, or all three. Suspected ureteral
injuries may be conrmed with an intravenous methy-
lene blue injection, the persence of dye in the operative
eld conrming injury.
Prevention
Injury to the ureter is often a complication of hyster-
ectomy or the mobilization of the colon for its resec-
Figure 618 An incision in the white line of Toldt on the left
side is connected to a surgically created opening in the gastro-
colonic omentum by a maneuver that pushes down upon the
colons splenic exure and then retracts it tangentially in a
coronal plane under direct vision and controlled tension. The
lienocolic ligaments thus exposed may be lysed using cautery
or sharp dissection, as dictated by their size and vascularity.
tion or for retroperitoneal exposure. For pelvic
conditions known to be inammatory, careful tracing
of the ureter from a proximal identication point can
usually avoid injury. Avoidance of ureteral injury in the
pelvis can best be accomplished by proximal identica-
tion after complete division of the ipsilateral white line
of Toldt. Few ureters identied close to the renal pelvis
are injured while being exposed in antegrade dissec-
tion. The ureter enjoys a relatively constant relationship
to the bifurcation of the common iliac artery, which
represents an additional anatomic landmark. Involve-
ment of a ureter by an obstructing pelvic cancer is
heralded by proximal ureteral dilatation; in this circum-
stance, the ureter cannot be freed externally, and
depending on the likelihood of curethe ureter will
have to be stented or its proximal segment diverted to
preserve excretion. Operations done on the uterine
cervix should proceed in close proximity to it if ureteral
injury is to be avoided.
Whether use of preoperatively placed ureteral stents
avoids ureteral injury in abdominal and pelvic surgery
is controversial and a matter of individual surgeon
choice. Gittes (personal communication, Peter Bent
Brigham Hospital, Boston, 1978) observed that place-
ment of a ureteral stent does not preclude injury to the
ureter in a scarred, inamed, brosed, or tumor-laden
retroperitoneumit just makes the injury crunchy.
Bladder Injury
Consequence
Urine leak or the need for subsequent surgery may
occur if bladder injuries are not recognized or are inad-
equately repaired.
 6 GENERAL LAPAROTOMY 83

Incision
in peritoneum Angle
of His
Esophagus

Stomach

A B

Figure 619 A, The perito-

neum overlying the gastro-
esophageal junction is incised C
transversely from the gastro-
esophageal junction on the
patients right side to the angle
of His. B and C, The nger
encircling the esophagus in the
mediastinum points toward the
right shoulder, and not trans-
versely, thereby precluding entry
into the well-vascularized region
of the high lesser curvature of
the stomach. D, The suture line
for repair of a distal esophageal
injury is encompassed within a
Nissen fundoplication performed
for that purpose. D

Repair If the bladder injury is incisional or otherwise self-

Injury to the intraperitoneal urinary bladder is readily
identied at laparotomy either by visualization of the
Foley catheter balloon or by the presence of urine in
the operative eld. As with suspected ureteral injuries,
methylene blue dye may be intravenously injected, its
presence noted in the operative eld conrming injury.
limiting, the edges of the defect should be identied
and the injury should be closed with a two-layer closure.
The inner layer is full thickness and the outer layer is
an imbrication.
Injuries to the posterior wall of the bladder are
approached transvesically and occur more often with
 84 SECTION I: GENERAL CONSIDERATIONS
vaginal surgery than during laparotomy. The transvesical
approach allows for trigonal visualization during repair.9,10
Injection of pigmented intravenous dyes may facilitate the
delineation of the injury.
A repaired bladder is typically decompressed for 10 days
to 2 weeks with a Foley catheter after repair, whether the
injury to the bladder is volitional (as for primary repair,
ureteral stent placement, or colovesical stula repair) or
accidental. An additional drain is placed near the repair
and brought out through the anterior abdominal wall. If
the extravesical drain has been dry, some surgeons dis-
continue the Foley without obtaining a radiologic study;
others perform a cystogram on all patients.
Prevention
Prevention of bladder injuries is best afforded by pre-
operative decompression with a Foley catheter for
pelvic surgeries, awareness of the position of the bladder
and the Foley balloon during dissection, and a method
of dissection of adhered visceral loops that stays close
to their antimesenteric surface and does not stray into
the retroperitoneal fat.
Vascular Injuries
Consequence
Bleeding may continue from unsecured vessels. Visceral
ischemia may result from occlusion of vessels essential
to organ perfusion.
Repair
Vascular injuries should be initially managed by an
attempt to obtain control proximal and distal to the
injury. As an injured vessel is isolated, one should be
able to tell whether it is a tributary of a major vessel that
can be sacriced or whether it is an essential vessel.
The injured portion of essential arteries should be
mobilized as much as is practical, isolated with vascular
clamps if possible, and repaired with nonabsorbable mono-
lament sutures. Rarely, the avulsion or damage to an
essential vessel will be sufciently great that completion
of the transection with end-to-end anastomosis or vascu-
lar graft placement is required. Because all such repairs of
transections carry the potential for thrombosis as the task
is being completed, some have suggested that a ush of
heparinized saline solution distal to the repair helps to
avoid thrombosis during occlusion for repair. Because the
reports of such repairs are as uncontrolled as their pre-
cipitating bleeds, the advantages of this approach are
unknown, and heparinization is usually far from the sur-
geons thoughts on the occasion of just having controlled
an exsanguinating bleed.
Although textbook achievement of proximal and distal
control is optimal, signicant vascular injuries occur pre-
cisely because the three-dimensional preinjury mobiliza-
tion is insufcient to allow the controlled isolation and
clamping routine that characterizes elective vascular
surgery. Mannick (personal communication, Brigham &
Womens Hospital, Boston, 1982) stated that one ques-
tion is diagnostic of whether a queried physician is a
surgeon or notwhether she or he is more respectful of
arterial or venous bleeding. The surgeon always chooses
venous. Venous injuries do not often allow the ease of
dissection of arterial injuries because the thin vein wall
predisposes repairs to further tearing with ongoing and
potentially exsanguinating hemorrhage. Accordingly, par-
ticularly with venous injuries, a temporary solution is
required in order to be able to see to complete the dis-
section. Three maneuvers may be used: application of Allis
clamps to the venotomy to further characterize the injury
and obtain exposure, application of a side-biting clamp to
the injury, or proximal and distal compression with sponge
sticks employed as surrogates for clamps and thereby facil-
itating further dissection and control (Fig. 620).
The portal vein is constituted of the conuence of the
superior mesenteric vein, inferior mesenteric vein, and
splenic vein. Injury to it is most often made in its exposure
during pancreaticoduodenectomy.
The superior mesenteric tributary of the portal vein may
be identied by an extended Kocher maneuver, which
reects the hepatic exure of the colon and identies the
mesenteric veins course beneath the surgical neck of the
pancreas, as described by Cameron.11 Alternatively, after
opening the lesser sac through the gastrocolic omentum,
the surgeon may identify and follow the middle colic vein
onto the superior mesenteric veins anterior surface. The
atraumatic separation of the anterior surface of the conu-
ence from the pancreas is testament that the disease has not
involved the veins wall; that the veins adventitial, but not
endothelial, surface has been exposed; and that a tunnel
can be developed between the anterior surface of the vein
and the surgical neck of the pancreas by the judicious use
of gentle cephalad blunt dissection (Fig. 621).
If hemorrhage from venous injury occurs because the
diagnosis of inseparability of vein from tumor was made
by blunt digital venotomy in this subpancreatic tunnel,
the injury should be initially addressed by packing the
tunnel. Cellulose or crystallized collagen products will
usually secure hemostasis in small tears or avulsion of small
branches. Larger rents represent one of the most unforgiv-
ing and poorly salvaged injuries in all elective surgery. The
best treatment is avoidance. Second best is to proceed to
rapid and complete exposure of the injury before extensive
blood lossin all but an exsanguinating situation. If the
patient is resectable or if preliminary maneuvers do not
stop the bleeding, efforts at more complete exposure of
the injury, including expeditious division of pancreatic
parenchyma, should rapidly follow the injury to facilitate
exposure.
Injury to the portal conuence during pancreaticoduo-
denectomy can also occur during the delivery and passage
of the proximal jejunum under the root of the mesentery
and into the subhepatic space or during the subsequent
dissection of the vein from the uncinate process of the
 6 GENERAL LAPAROTOMY 85

Figure 620 Methods of

controlling venous hemorrhage.
A, Allis clamps are sequentially
applied to the venotomy to
close it.The clamps are adjusted
to produce minimal encroach- A
ment on the venous lumen and
then undersewn to complete
the lateral venorrhaphy. B, A
side-biting (Satinsky) clamp is
applied to the vein, excluding
the injured portion. This
maneuver requires that at least
50% of the vessel be able to be
clamped, which is not possible
in all circumstances. Venotomy
is closed under direct vision
with a running suture, and the
clamp is released. C, Sponge
stickssmall gauze pads
loaded on ringed forcepsare
used as surrogates for vascular
clamps in an attempt to slow or
stop bleeding and to facilitate
visualization of the injury. This
may facilitate direct repair,
application of Allis clamps, or
further dissection to enable a
side-biting clamp to be placed. B C

pancreas. In both cases, the culprit is likely the avulsion
of side branches of the portal vein, which can be exposed,
closed with Allis clamps and undersewn. Exposure of the
injury and salvage of the patient with such an injury may
demand the presence of several experienced vascular sur-
geons. Packing of the injury should occur until they are
available.
Prevention
As with all injuries, knowledge of the normal anatomy
and its variants as well as unhurried dissection facilitates
avoidance of injury.
Problems of Fascial Closure: Wound Infection,
Wound Dehiscence, Evisceration, and
Incisional Hernias
Consequence
The surgical literature has historically and repetitively
warned of the scal and physiologic cost of abdominal
wound disruption. Contemporary surgeons who protest
that such costs are exaggerated on the grounds that few
additional hospital days are now required to care for
patients with wound infections often have not included
the cost of dressings, outpatient nurse visits, and sub-
sequent surgeries in their calculations.
Repair
Fascial closures may fail subtly or dramatically, early or
late. Wounds may have disrupted subclinically at the
fascial level in the immediate postoperative period only
to present with an incisional hernia much later on or
may herald early dehiscence by a disproportionate dis-
charge of serosanguinous uid through the skin in the
immediate postoperative period. Evisceration is the
extrusion of bowel through fascia and skin disrupted in
the immediate postoperative period. Whereas the latter
condition is clearly the most urgent and psychologically
distressing, as the patient is beside himself or herself
both guratively and literally, both dehiscence and evis-
 86 SECTION I: GENERAL CONSIDERATIONS
Portal vein
Superior
mesenteric vein
ceration are signicantly morbid events in an already
compromised patient. Whereas a small dehiscence in a
densely adhered abdomen may be able to be managed
nonoperatively, it will virtually always eventually result
in a signicant ventral hernia. The greater concern is
that, if ignored, a serosanguineous herald discharge
may foreshadow evisceration. In this situation, consid-
eration should be given to returning the vast majority
of dehisced patients to the operating room for explora-
tion and assessment of the potential for reclosure. No
two such patients are alike, making the examination of
the merits of the competing remedies difcult. In
patients with fascial disruption attributable to simple
failure to secure the knot or to inadequate placement
of sutures, reclosure may be attempted with more
attention to detail. Patients who have either necrotiz-
ing infection or extensive disruption of the fascial edges
by infection or sutures cutting through the closure may
require a different approach. Mass closure of the wound
with retention sutures placed through all layers of the
abdominal wall has been advocated as either a primary
or a secondary approach to closure in hopes of mini-
mizing evisceration. Its success in secondary closure
probably relates to its ability to obtain wider fascial
purchase and to gather and appose musculofascial tissue
to bring together and buttress the wound edges.
Prevention
Only some of the determinants of wound healing are
under the surgeons direct control. Others are the
Figure 621 Insertion of the index nger beneath the
surgical neck of the pancreas to verify that a dissection plane
exists at the origin of the portal vein beneath the pancreas.
The surgeon follows the anterior surface of the superior
mesenteric vein as it courses beneath the pancreas to join
the splenic and inferior mesenteric veins at the portal
conuence.
products of comorbid metabolic or hematologic disease;
and still others are byproducts of the patients body
habitus. The surgeon who performs emergent or urgent
laparotomy is often asked to accept some determinants
of deciencies in wound healing in exchange for the
need to urgently address the presenting complaint.
When possible, the postponement of elective surgery
until adverse comorbid conditions can be corrected or
optimized is a basic tenet of surgery. Intuitive measures
include the treatment of comorbid infectious disease when
a clean case or prosthetic implant is anticipated, the opti-
mization of glucose control in the perioperative period as
a means of demonstrably decreasing wound complica-
tions, the maintenance of tissue oxygen tension and the
correction of nutritional deciencies. Although it makes
intuitive sense that a patient depleted of carbohydrate and
fat reserves would metabolize muscle protein and have
teleologically diminished incentives to synthesize the
protein modulators of the immune response (thereby fos-
tering impaired wound healing), it is difcult to demon-
strate that restoration of a normal albumin or weeks of
preoperative hyperalimentation create demonstrable sur-
vival benet in the recovery of large cohorts of hospital-
ized postoperative patients.
Wound strength is conferred by the dermal and fascial
layers only. However, heroic hyperpronative contortional
efforts to avoid incorporation of muscle into a fascial
closure often paradoxically result in a suboptimal purchase
of the fascia itself, thereby facilitating postoperative wound
disruptions. The surgeons attention to detail, technique,

and choice of suture material are important. However, as
with all aspects of surgery, the quality of the surgical
closure is determined more by the caliber of the surgeon
than by the caliber of her or his suture material. Kocher
clamps or intra-abdominal retractors should allow the
operating surgeon the opportunity to visualize the closure
needle as it traverses the parietal peritoneum as she or he
protects the underlying abdominal viscera. The ideal assis-
tant to the surgeon performing abdominal closure will
retract the skin and subcutaneous tissues to allow optimal
visualization of the fascial layer. Care should be taken not
to catch the dermis in the fascial closure, which causes a
painful dimpling of the skin immediately adjacent to the
wound. Either such a stitch must be redone or the dermis
must be released prior to skin closure.
Most abdominal wounds in adults should be closed
with monolament fascial suture material of zero caliber
or larger. Smaller-caliber material may fracture as the
abdominal wound elongates during muscular loading and
as the intra-abdominal pressure increases after closure.
Increasing tension on the wound has been demonstrated
to approach perfusion pressure in some animal models of
wound failure, yet no reliable bedside tool exists for the
calibration of tension on fascial sutures during wound
closure. Advocates of interrupted closure decry the
Lindbergh principle, whereby, like Charles Lindberghs
reliance on the reduced weight of the one-engine plane
for his successful transatlantic ight, the integrity of fascial
closure resides with the one terminal knot securing the
running closure. They also cite potential strangulation of
the suture line as the running suture tightens periopera-
tively. However, discounting rare circumstances in which
the terminal knot of a running closure unties, the theo-
retical advantages of intersutural perfusion to the wound
edge have not produced a superior rate of intact fascial
closure for surgeons using the interrupted technique. A
likely explanation for this is that the tissue tension from
adjacent sutures creates equivalent ischemia to that
imposed by a running stitch. Meta-analyses and prospec-
tive randomized studies attempting to identify comparable
patients and closing them with interrupted or running
closures have produced similar results; a slight advantage
shown in some randomized studies favors the running
suture group.
Assuming that an adequate caliber suture is chosen and
that the knot(s) remains secure, a continuous suture pro-
viding a suture lengthtowound length ratio of 4 : 1 is
most often advocated, based on clinical experience and
burst-strength experiments in laboratory animals (Fig.
622). These data argue that even the hypothetical rela-
tive weakness of the midline wound to its transverse coun-
terpart are eliminated by the placement of sutures at least
1 cm from the wound edge, incorporating all layers of
fascia and muscle, and progressing no more than 1 cm
with serial bites.12
A normal inammatory response in a well-nourished
host with intact cellular, vascular, and chemical mediators
6 GENERAL LAPAROTOMY 87
1 cm
1 cm
1 cm
Figure 622 Optimal fascial closure provides a suture length
towound length ratio of 4 :1.
is optimal for normal wound healing. The link between
wound infection and development of a subsequent ventral
hernia is well established, as is the reduction in tensile
strength of wounds closed by secondary intention com-
pared with those closed primarily. The hope that a wound
might heal with primary closure should not override
reasoning developed through evidence-based imperatives
that suggest secondary closure. The National Nosocomial
Infections Study (NNIS) classication of wounds as clean,
clean contaminated, or grossly infected is intended to
stimulate the surgeon to choose proper closure material
and to decide whether to leave the skin open based on
risk factor assessment once fascial closure has been
effected.13
Sutures with interstices and whose constitution incites
an inammatory response have generally been abandoned
in favor of monolament synthetic sutures, in the hope
that the latter would minimize the chances for wound
infection. Among monolaments, suture material has
been developed that absorbs at a time when inherent
tensile strength of the wound would be presumed to have
developed. With the liability that they remain as a foreign
body indenitely and are often the source of patients pain
or other local difculties, nonabsorbable monolament
sutures for patients at high risk of wound disruption none-
theless remain the choice of many surgeons.
Avoidance of wound infection and its sequelae is facili-
tated by skin preparation, by instrument sterilization, and
by the sterile environment created in the operating room.
Skin preparation has historically been accomplished with
a bacterial desiccant such as povidone-iodine (Betadine),
but chlorhexidine and its analogues have recently been
advocated as preparations whose toxicity to bacteria is
longer lasting. Some have suggested that overzealous use
of the cautery and fat necrosis predispose to wound infec-
tion. Others have claimed that wound protector devices
minimize inoculation of the subcutaneous tissue during
laparotomy in clean-contaminated cases.
As treatment for wound infection involves removal of
the skin closure and drainage of the extrafascial subcutane-
ous space, it makes sense to eliminate the skin closure
completely in grossly contaminated wounds or in wounds
in which the subcutaneous tissue has the potential to have
received a sufcient inoculum to make wound infection
likely. Logarithmic reductions in bacterial counts have
been shown to be able to be effected with serial dressing
 88 SECTION I: GENERAL CONSIDERATIONS
changes.14 When bacterial inoculation is combined with
ischemic or bacterial compromise of the subcutaneous
tissues, some have advocated the use of enzymatic dbride-
ment agents. Once the wounds bacterial counts have
been judged to be decreased on clinical or quantitative
determination, a decision can be made as to whether to
secondarily tape it shut or close it with sutures or whether
to apply a vacuum sponge to the subcutaneous tissue,
achieving both wound contraction and contaminant
evacuation.15
How to best avoid visceral injury during abdominal wall
closure is a matter of personal choice by the operating
surgeon. Malleable retractorseither unsheathed or aug-
mented by rubber extensions as exemplied by the sh
retractoror subfascial layering of Mikulicz pads are used
by some surgeons to keep the abdominal viscera away
from the parietal peritoneum during closure. However,
nothing focuses the surgeons attention on the safety of
A B
Fascial
needle
Dermis
C pain.
the process like the presence of his or her own hand in
the wound as the fascial closure proceeds. What should
be in the nondominant hand of the surgeon is a matter
of controversy (G. Steele, personal communication,
Brigham & Womens Hospital, Boston, 1983). Steele
advocated that the fascial closure stitch enter the abdomen
into a space created by the unadorned cupped nondomi-
nant hand. This technique shields the viscera so that they
intrude no further than that hands dorsal surface. Hooking
the nondominant hands index and third ngers on the
other side of the incision allows visualization of the pari-
etal peritoneum as the fascial stitch leaving the abdomen
is placed. This maneuver requires that the surgeons two
ngers bring the abdominal wall forward as the assistant
retracts skin and subcutaneous tissue. Advocates of this
technique note that absence of an instrument in the sur-
geons left hand facilitates its use for retraction and frees
it for the tying function (Fig. 623). Other surgeons insist
Figure 623 A, Closure of the abdominal wall with no instru-
ment in the nondominant hand. The nondominant (left) hand is
inserted into a midline wound. B, Elbow extension as the wrist is
positioned at 180 elevates the abdominal wall as the cupped hand
protects the bowel during fascial suture placement. C, Two-
ngered hooking of the other side of the abdominal wall facilitates
safe placement of sutures by allowing the curved portion of the
needle to clear the abdominal viscera before it engages the fascia.
The assistant pulls the skin and subcutaneous fat away from the
closure so that it is not retracted downward, which produces

Figure 624 The sheathed SuturTek needle
application device. The rst squeeze of the
device permits the needle to engage the tissue
and resheaths it. The second squeeze permits
disengagement and movement of the device to
engage the sewed side of the incision while
simultaneously resheathing the needle.
that the surgeon should always have two instruments in
hand and that an instrument such as a forceps be utilized
in addition to the retraction provided by the assistants
Kocher clamp. If an instrument is to be used by the
surgeon to grasp fascia, it should be a sturdy toothed
forceps or Kocher clamp capable of exerting substantial
anterior traction on the fascia.
Even with a focused team, optimal retraction, and
denitive exposure of the fascial layers, closure of the
abdominal wall is a common place for the surgeon or
her or his assistants to incur needlestick injuries. The
substitution of blunt needles for sharp needles to close
fascia has been advocated by the American College of
Surgeons in hopes of addressing this problem.16 In addi-
tion, sheathed needle devices, such as that developed by
SuturTek, Incorporated, have sought to provide protec-
tion, automate the pronation necessary to achieve ade-
quate fascial purchase (Fig. 624), provide equivalent
purchase without hypersupination or hyperpronation, and
protect the operating surgeon and her or his assistants.17
Whether the use of blunt needles and such devices will,
in fact, favorably affect the incidence of needlestick injury
remains to be seen.
Overzealous attempts by anesthesia personnel to coor-
dinate abdominal wall closure with emergence from anes-
thesia occasionally produce a patient emerging from
anesthesia near the end of the operation, but before the
nal fascial suture has been placed. This practice places the
patient at extraordinary risk for injury to the underlying
viscera as the patient strains and pushes these viscera
against the anterior abdominal wall, compromising visu-
6 GENERAL LAPAROTOMY 89
alization, placement, and tying of the fascial stitch.
Remarkably, the reex response to the surgeons observa-
tion that relaxation is inadequate is more often a report
of how many twitches are evident on a neuromuscular
blockade monitor rather than deepening of the anesthetic,
as if a monitors output should trump the experiential data
being reported by the surgeon from the operative eld. It
is better for the patient to spend a few more moments
under an appropriate level of anesthesia than to compro-
mise fascial closure or risk injury to intestine.
If the bowel is accidentally or otherwise impaled or
distorted during fascial closure, the needle should be
backed out and the injury to the bowel wall assessed. It
is better to acknowledge the presence of signicant tether-
ing of the bowel to an abdominal wall adhesion with
release of the intestine or to take the time for visceral
repair after signicant tearing than to incur an unnecessary
postoperative obstruction or intestinal stula.
When the Fascia Should Not Be Closed:
The Abdominal Compartment Syndrome
Consequence
Tight abdominal closures have been implicated in vis-
ceral hypoperfusion and decreased respiratory excur-
sion. Extrapolating from the physiologic compromise
witnessed by pediatric surgeons in their care of patients
with gastroschisis and omphalocele closure, adult sur-
geons caring for massively resuscitated trauma victims
have described a syndrome of restrictive small volume
ventilation, visceral hypoperfusion, and oliguria known
 90 SECTION I: GENERAL CONSIDERATIONS
30 40
25
20 50
15
10 60
5 0
Water manometer
or transduced
equivalent Foley catheter
with balloon
inflated
3-way Foley
stopcock catheter
(for flushing)
as the abdominal compartment syndrome.18 Investigated
by Harmann in a dog model of increased intra-
abdominal pressure19 and subsequently in humans
using manometrically measured bladder pressures as
surrogates for intra-abdominal pressures, the evolving
literature suggests leaving the skin and fascia open after
acute interventions in which closure of the abdomen
would create such elevated pressures and opening the
abdomen (and leaving it open) when such parameters
exist in an acutely ill, but unoperated, patient.20
The abdominal compartment syndrome is suspected
based on the clinical circumstances of tight abdominal
closure or massive abdominal distention and conrmed by
manometric pressure measurements of uid within the
urinary bladder (Fig. 625). Measurements of 22 mm
H2O or greater are believed to represent elevations that
compromise glomerular ltration and perfusion pressure
in the clinical setting of oliguria, increased peak ventilatory
pressures, and shock.
Repair
Postponing denitive closure until such time as the
abdominal wall has accommodated and the interstitial
uid has been dispersed allows for delayed primary
closure of the fascia. However, unlike the situation in
neonates, in which the operation is often classied as a
clean case and staged closure is anticipated with several
intervening months permitting accommodation, adults
suffering abdominal compartment syndrome have often
been acutely injured exogenously or iatrogenically,
with a contaminated wound and ongoing concern for
the integrity of the intra-abdominal viscera. Under such
circumstances, temporary containment of the abdomi-
nal viscera without benet of fascial, skin, or prosthetic
Figure 625 Method of measuring intra-
abdominal pressure using a Foley catheter.
The bladder is transduced to either a monitor
screen or a water manometer.
closure of the abdominal wall must be effected because
denitive closure would produce intra-abdominal pres-
sures high enough to compromise perfusion pressure
and a prosthetic mesh augmenting the abdominal wall
would likely become infected.
To allow the abdomen to remain open during a period
of known collagen deposition and adhesion formation,
and to enable its subsequent closure without adhesiolysis,
strategies have been developed for short-term prevention
of adhesions of viscera to the anterior abdominal wall at
the incisions edge. Originally, the Bogota Bag, a resteril-
ized silicone bag recycled after use for storage of sterile
irrigant or intravenous uid, was adapted for use as an
intravenous visceral bag similar to the Schuster silo used
in infants for treatment of omphalocele and gastroschi-
sis.21,22 The bag is sutured to the wound edges. A modi-
cation of the Bogota bag can be constructed in any
operating room by apposing the sticky sides of two plastic
surgical drapes. Trimmed to a size larger than the fascial
defect, the large, double-thickness plastic sheet is then
placed into the peritoneal cavity between the viscera and
the anterior abdominal wall in a way that precludes contact
of the visceral peritoneum with the parietal peritoneum at
the wounds edges. Moist towels, subcutaneous suction
drains, and a large plastic drape placed over the entire
apparatus preclude both the accumulation of additional
uid under the dressing and the leakage of interstitial uid
into the bed, thereby facilitating nursing care (Fig. 626).
Interval returns to the operating room as the interstitial
uid recedes permit sequential assessment of the potential
for denitive closure.
Other circumstances, such as objective loss of the ante-
rior abdominal wall because of blast or bullet injury, pre-
clude primary closure of the abdominal wall. Compartment
 6 GENERAL LAPAROTOMY 91

Suction
drain Plastic
sheet

Towels

Muscle/fascia Small Plastic sheets

intestine

Figure 626 Creation of a modied Bogota bag for the management of the open abdomen. The sticky sides of two plastic surgical
drapes are apposed and then tucked under all corners of the abdominal wound to preclude adhesion of visceral peritoneum to parietal
peritoneum. Moist towels and suction drains are then placed. A third plastic drape completes the closure. Interstitial uid is collected by
suction applied to the suction drains.

release, tissue transfer, absorbable meshes, intestinal sub-

mucosal xenografts, and autogenous split-thickness skin
grafts applied after the establishment of a base of granula-
tion in such wounds have been utilized as late-closure
measures. Wound management when the skin, the fascia,
or both cannot be closed is facilitated by nutritional sup-
plementation and supportive care directed at the establish-
ment of a granulating base and the avoidance of intestinal
stula formation. When bacterial counts in the wound are
demonstrably low as determined by either quantitative
wound culture or qualitative examination of wound
drainage, ambulatory wound care may be facilitated by the
application of a negative-pressure vacuum assisted closure
(VAC) device.23 This delivers negative pressure to wounds,
evacuates accumulating uid, and has been applied either
to the subcutaneous space or onto a granulating bed when
the fascia is not intact. Application of negative pressure to
the wound removes transudate and light exudative mate-
rial and promotes wound contraction and patient mobil-
ity. The VAC device may be applied whether or not the
fascia is present once a granulating base has been estab-
lished. It may be used in either hospitalized patients or
outpatients. Recently, some have advocated a modica-
tion of the VAC system to treat complex wounds where
a granulating base and an intestinal stula coexist (Fig. VAC
627).24 This modication pouches the stula, which is Intestinal fascia device
Normal and pouch
excluded from the VAC dressing when possible, while the abdominal Sponge Nonadherent
VAC exerts negative pressure on the granulations. In pre- wall gauze
Plastic
liminary reports, such patients are said to have increased sheet
mobility and decreased length of stay.

Prevention
Abdominal compartment syndrome occurs in the
setting of increased intestinal uid due to massive resus-
citation and multisystem failure. The surgeon is usually
not able to affect the cause. Prevention is directed at
the limitation of iatrogenic contributions to multisys-
tem organ failure.
Granulation
tissue
Figure 627 Modication of the vacuum assisted closure (VAC)
device to accommodate an intestinal stula within a granulating
base. The stula is pouched, and the granulating base is protected
with nonadherent gauze to permit the application of negative pres-
sure on the VAC sponge.
 92 SECTION I: GENERAL CONSIDERATIONS
Infectious Complications of Laparotomy:
Postoperative Intra-Abdominal Abscess and
Postoperative Enterocutaneous Fistula
Consequence
Sepsis, shock, multiple subsequent surgeries, and death
may occur if the infectious problem is not approached
systematically.
Repair
Infection may be the reason for laparotomy or it may
develop insidiously as a complication in the postopera-
tive period, masked by the paralytic ileus that accom-
panies most intra-abdominal surgeries. Postoperative
ileus is believed to be a vestigial, primitive, and teleo-
logic reex aimed at limiting peristalsis and resultant
peritoneal soilage through enterotomies of animals
wounded in the wild. In patients, an ileus may allow 3
to 7 days to elapse before the symptoms of anastomotic
failure, neglected perforation, or unnoticed enterotomy
become manifest with resumption of peristalsis.
Therefore, any hyperdynamic, febrile postoperative
abdominal surgical patient should have these diagnoses
considered.
Infected uid collections in the abdomen are classied
as either communicating or not communicating with the
intestine. Noncommunicating collections (pure abscesses)
are typically the sequelae of inoculation of a portion of
the peritoneal cavity with visceral contents or external
contaminants as part of either the primary pathology or
its treatment. Their presence implies lack of evacuation at
the rst procedure or a small visceral leak that rapidly
sealed after inoculation. They are more often discovered
by abdominal imaging done as part of an evaluation for
fever than by history or physical examination, although
some pelvic collections may be felt on rectal or pelvic
examination and subphrenic collections may be suspected
by the presence of ipsilateral shoulder pain.
Noncommunicating abscesses can almost always be
treated with catheter drainage by an experienced interven-
tional radiologist, who also plans the trajectory of the
drainage approach. Ultrasonography has yielded to
computed tomography scan in the diagnoses of most
intra-abdominal abscesses. Both modalities are used by
interventional radiologists to accurately and safely approach
and drain the collections they discover. Only rarely must
a subphrenic abscess be approached surgically through the
bed of a resected lower thoracic rib (Fig. 628) because
the radiologists are not able to identify a safe trajectory
for percutaneous puncture.
Enterocutaneous stulas may occur spontaneously in
parasitic disease and in Crohns disease or as the result of
anastomotic failure or iatrogenic injury. The latter typi-
cally manifests in one of three ways:
1. The communicating abscess. In this circumstance, an
intra-abdominal uid collection identied radiographi-
cally is initially believed to be a noncommunicating
abscess, but the initial drainage of purulent material is
eventually followed and supplanted by ongoing drain-
age of enteric material. Percutaneous drainage thus
converts the intra-abdominal collection to an enterocu-
taneous stula. Collections with this potential usually
contain air as well as uid.
2. Spontaneous drainage of enteric contents occurs
through the original laparotomy incision or a drain site,
usually related to anastomotic failure, unrecognized
pathology, enterotomy unrecognized at the rst opera-
tion, or visceral incorporation into fascial closure.
3. Slow dehiscence. In this circumstance, a single loop of
bowel is adhered to both sides of an abdominal wound.
As the fascial closure disrupts, adhesion of the loop to
both sides persists, resulting in intestinal wall disrup-
tion and stulization into the wound (Fig. 629).
Berry and Fischer25 identied ve phases of manage-
ment of a stula: recognition/stabilization, investigation,
decision making, implementation of denitive therapy,
and healing. Sequential attention is paid to uid and elec-
trolyte repletion, drainage of sepsis, control of stula
drainage, and local skin care. Nutritional support is then
instituted, and upon stabilization, typically 7 to 10 days
after presentation, a stulogram, upper or lower gastroin-
testinal contrast study, or other advanced radiographic
study is performed.
Many stulas will close in the absence of conditions rst
described by Welch and coworkers26distal obstruction,
cancer, foreign body, inammatory bowel disease, or
ongoing associated infection. It is reasonable to persist
with supportive measures for stula care only if progress
is being made and if the determinants of persistent stu-
lization are absent. The additive psychological distress
of patient and surgeon and the desire of both to see the
problem xed should not push the surgeon to early
laparotomy, given that stulas often declare themselves
precisely at the time when inammatory conditions from
the rst surgery make the abdomen most hostile to a
subsequent surgical approach. Although well intentioned,
the surgeon seduced to operate for anything other than
uncontrolled sepsis or intestinal necrosis during this early
period will often nd that he or she has increased, rather
than reduced, the number of intestinal stulas. One
important exception to this admonition is the desirability
of proximal diversion as an adjunct to stula control in
the case of large bowel stulas or when such diversion
can stop ongoing soilage, can be readily accomplished in
an area remote from the epicenter of the reparative process
and facilitates efuent control. Whereas a direct operative
approach to a leaking sigmoid colon anastomosis through
the original operative eld, for example, might be difcult,
proximal diversion with either ileostomy or transverse
loop colostomy outside the original operative eld (and
therefore distant from the attendant adhesions) may
greatly facilitate attempts at catheter drainage of the
 6 GENERAL LAPAROTOMY 93

12th rib
A Periosteum B Latissimus dorsi
muscle

Liver
Perirenal fat

Diaphragm
Diaphragm
Bed of
C D 12th rib

Right subphrenic space Liver

Right post. Abscesses

subhepatic
Ribs

Right
ant.
subhepatic
Figure 628 A, Technique of
drainage of subphrenic abscess by
posterior resection of a oating
rib. B, The rib is exposed along its
course and amputated. CE, The
subhepatic space is entered caudal Kidney
to the visualized pleura, and the
suction drains are placed. E

leaking uid and control of sepsis. Denitive operation to
address the site of the colonic abnormality may be con-
ducted in a minimally contaminated environment at a
subsequent time. The protecting stoma may be either left
in place as the distal defect is repaired in anticipation
of closure at a third operation or taken down at the second
surgery. Usually, repairs distal to a diversion in this setting
are radiologically veried to be intact before the stoma is
closed. In general, stoma closures are elective operations;
a distal radiographic study is universally useful both as
a preoperative planning tool and to identify persistent,
synchronous, or clinically occult pathology.
Prevention
Identication of visceral injury, whether endemic to
the pathology or iatrogenically created at the time of
 94 SECTION I: GENERAL CONSIDERATIONS
Thinning of
Viscus tethered viscus as
to both sides wound
of incision dehisces
Granulation
tissue overlying
exposed viscera
Fascia
Skin
Figure 629 Enterocutaneous stula development by slow dehiscence. As a single loop of bowel is tethered between separating fascial
edges, enterotomy and stula develop.
operation, allows repair, externalization, or drainage as
appropriate.
Intestinal Obstruction after Laparotomy
Consequence
Hospitalization for nasogastric decompression and
reoperation for intestinal obstruction are common
occurrences after an initial abdominal operation.
Repair
Unless it is believed to be the result of direct injury,
tethering, occlusion of the bowel during fascial closure,
or irreversible twisting of the bowels mesentery on its
replacement into the abdomen, most obstructions
occurring during the immediate postoperative period
can be managed with nasogastric suction rather than a
second operation. The diagnosis of early postoperative
obstruction is made on clinical grounds after careful
inspection of the abdominal wall of a recently operated
patient for hernia or fascial defect. Typical symptoms
of abdominal pain and vomiting, with or without leu-
kocytosis and fever, lend support to the diagnosis but
also occur with normal postoperative ileus. When a
persistent postoperative ileus should be reclassied as a
small bowel obstruction is a highly subjective determi-
nation awaiting a universally accepted denition of
postoperative obstruction. Because the presence or
absence of bowel sounds is increasingly denigrated as
an important physical distinction, and as third-party
payors push for early discharge and fast-tracking of
patients, the early feeding of patients with physiologic
intestinal atony have resulted in patients being classied
as having early postoperative obstruction when they
were simply fed too early in their postoperative course
and then became distended or vomited as a result.
Division and exterioralization
of lumen of bowel as fixed
tethering points follow fascial
edges during dehiscence.
Plain lms of the abdomen, as with patients developing
obstructive symptoms remote from surgery, show dilated
loops of small bowel. Air-uid levels may be present in
both circumstances, with variable amounts of gas present
in the colon. The absolute absence of gas in the colon,
when seen in any intestinal obstruction, is concerning but
does not portend intestinal ischemia with the same fre-
quency in the immediate postoperative period as the same
ndings occurring at a time remote from the rst surgery.
The bowel must truly be suspected to be threatened to
warrant operation during the acute phases of brinous
inammation. The vast majority of immediate postopera-
tive obstructions can be managed nonoperatively with
nasogastric suction, judicious uid management, and
repletion of electrolytes, whereas such a strategy of near-
universal nonoperative management would likely endan-
ger substantial numbers of patients developing obstruction
long after their rst operation.27
Prevention
Prevention of intestinal obstruction has interested
surgeons because they themselves create adhesions
after all types of abdominal surgery and are thus
aware of the morbidity of both iatrogenic and naturally
occurring obstruction. Various mechanical and chemi-
cal means have been used in attempts to prevent
postoperative small bowel obstructions, particularly
by obstetricians and gynecologists who are concerned
not only with intestinal dysfunction but also with
infertility.
Noble28 incorrectly proposed that orderly arrangement
of small bowel loops within the abdomen, facilitated by
seromuscular tacking sutures, would reduce the incidence
of recurrent obstruction. Others advocated the use of long
intestinal tubes, introduced as preformed stents into the
small intestine, to serve the same function. Neither tech-

nique has affected the incidence of recurrent obstruction
durably enough to be widely utilized.29
Dextran, steroids, antibiotic irrigation solutions, and
limitation of radiation elds during radiation therapy
have been utilized in attempts to minimize postoperative
small bowel obstruction, particularly in patients undergo-
ing radiation to the pelvis after gynecologic or related
operation.
The latest and most promising topical product used for
prevention is sodium hyaluronate carboxymethylcellulose
(Sephralm). Becker and associates30 sought to standard-
ize a clinical model by wrapping the Sephralm around
the peristomal parietal peritoneum of freshly created
stomas. Sephralm appeared to reduce adhesions around
the stoma when it was inspected on reversal, but critics of
the model protested that peristomal adhesions are not a
common, reproducible, or signicant clinical problem.
Thus, it was unclear whether the relative absence of
adhesions around some stomas at the time of reversal was
good chemistry or good luck. A more recent large, multi-
institutional prospective, randomized study purported to
vindicate the use of the compound in demonstrating fewer
reoperations and hospitalizations for small bowel obstruc-
tion in patients treated with Sephralm and followed for
5 years.31 However, the study did not control for the
threshold of surgeons to operate nor for the lack of
uniform approach from surgeon to surgeon. Unfortu-
nately, such lack of controls is pervasive in the small bowel
obstruction literature, making any assessment of an inter-
ventions impact difcult. Indeed, the ability to assess the
efcacy of any intervention for small bowel obstruction is
hampered by the heterogeneous nature of intestinal
obstructions, the threshold for subsequent operation for
obstruction, the universal proclamation of adhesions as
the cause by the biased operating surgeon, the nancial
rewards of operating, and the industrial funding of many
studies.32 Conversely, a study requiring demonstrably
dead bowel as an endpoint because of its denitiveness
would be correctly judged unethical. As a result, whether
any preventive strategy affects adhesion formation remains
controversial.
CONCLUSION
Those privileged to enter the abdomen surgically should
be aware of the spectrum of disease they might encounter
or create and be globally capable of managing the patients
in and out of the operating room. The decision to cross
the threshold from nonoperative to operative intervention
for abdominal pathology carries with it the responsibility
to carry the patient through all events presented by both
the disease and the intervention and directs whether an
open or a laparoscopic approach is chosen. Abdominal
interventions are grounded in well-established principles
of nutrition, infection control, dissection, abdominal wall
6 GENERAL LAPAROTOMY 95
repair, visceral repair, and surgical principles developed by
surgeons for surgeons. In stark contrast to those who
would attribute complications to systems failure or fatigue,
surgeons attribute complications in abdominal surgery to
disease processes or to themselves.
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1. Bristow RG, Hill RP. Molecular and cellular basis of
radiotherapy. In Tannock IF, Hill RB (eds): The Basic
Science of Oncology, 3rd ed. New York: McGraw-Hill,
1998; pp 295321.
2. Thorek P. Anatomy in Surgery. Philadelphia: JB Lippin-
cott, 1951; pp 413418.
3. Sheldon GF, Lim RC, Yee ES, Petersen SR. Management
of injuries to the porta hepatis. Ann Surg 1985;202:
539.
4. Mattox KL, McCollum WB, Beall AC Jr, et al. Manage-
ment of penetrating injuries of the suprarenal aorta. J
Trauma 1975;15:808.
5. Tera H, Aberg C. Tissue strength of structures involved in
musculo-aponeurotic layer sutures in laparotomy incision.
Acta Chir Scand 1976;142:349.
6. Martin CJ, Kennedy T. Reconstitution of the pylorus.
World J Surg 1982;6:221225.
7. Cohn LH. Local infections after splenectomy: relationship
of drainage. Arch Surg 1965;90:230.
8. Glatterer MS, Toon RS, Ellestad C, et al. Management of
blunt and penetrating external esophageal trauma. J
Trauma 1985;25:784792.
9. Cetin S, Yazicioglu A, Ozgur S, et al. Vesicovaginal stula
repair: a simple suprapubic transvesical approach. Int Urol
Nephrol 1988;20:265268.
10. Leng WW, Amundsen CL, McGuire EJ. Management of
female GU stulas: transvesical or transvaginal approach
19851988. J Urol 1998;160(6-1):19951999.
11. Cameron JL. Rapid exposure of the portal and superior
mesenteric veins. Surg Gynecol Obstet 1995;176:395.
12. Israelsson LA, Johnson T, Knutsson A. Suture technique
and wound healing in midline laparotomy incisions. Eur J
Surg 1996;162:605609.
13. Culver DH, Horan TC, Gaynes RP, et al. Surgical wound
infection rates by wound class, operative procedure and
patient risk index. Am J Med 1991;91(Suppl 3B):1535.
14. Pollock AV. The treatment of infected wounds. Acta Chir
Scand 1990;156:505513.
15. Morykwas M, Argenta L, Touchard R. Use of negative
pressure to promote healing of pressure sores and chronic
wounds. Proceedings of the Annual Conferences of
Wound, Ostomy, and Continence Nurses Association, July
10, 1993, San Antonio, TX.
16. Committee on Perioperative Care. American College of
Surgeons. Statement on blunt suture needles. Bull Am
Coll Surg 2005;90:11.
17. Davis M. Advances in engineered sharps injury prevention
technology: suturing. In Davis M (ed): Advanced Precau-
tions for Todays OR: The Operating Room Professionals
Handbook for the Prevention of Sharps Injuries and
Bloodborne Exposures, 2nd ed. Atlanta: Sweinbinder,
2001.
 96 SECTION I: GENERAL CONSIDERATIONS
18. Burch JM, Moore EE, Franciose R, et al. The abdominal
compartment. Surg Clin North Am 1996;76:833.
19. Kaufman CR, Cooper GL, Barcia PJ. Polyvinyl chloride
membrane as temporary fascial substitute. Curr Surg
1987;44:3134.
20. Balogh Z, McKinley BA, Holcomb JB, et al. Both primary
and secondary abdominal compartment syndromes can be
predicted early and are harbingers of multiple organ
failure. J Trauma 2003;54:848.
21. Burch JM, Ortiz VB, Richardson RJ, et al. Abbreviated
laparotomy and planned reoperation for critically injured
patients. Ann Surg 1992;215:476484.
22. Schuster SRA. New method for the staged repair of large
omphaloceles. Surg Gynecol Obstet 1967;123:837850.
23. Brock WB, Barker DE, Burns RP. Temporary closure of
open abdominal wounds: the vacuum pack. Am Surg
1995;61:30.
24. Goverman J, Yelon J, Platz JJ, et al. The stula vac, a
technique for management of enterocutaneous stula
arising within the open abdomen. Report of 5 cases. J
Trauma 2006;60:428431.
25. Berry SM, Fischer JE. Enterocutaneous stulas. Curr
Probl Surg 1994;31:469576.
26. Edmunds LH, Williams GH, Welch CE. External stulas
arising from the gastrointestinal tract. Ann Surg
1960;152:445471.
27. Pickelman J, Lee RM. The management of patients with
suspected early post-operative small bowel obstruction.
Am Surg 1989;210:216.
28. Noble TG. Treatment of Peritonitis and Its Aftermath.
Indianapolis, IN: AV Grindle, 1945.
29. Sprouse LR II, Arnold CL, Thow GB, Burns RP. Twelve
year experience with the Thow long intestinal tube: a
means of preventing post-operative bowel obstruction. Am
Surg 2001;67:357360.
30. Becker JM, Dayton MT, Fazio VW, et al. Prevention of
post-operative abdominal adhesions by a sodium hyaluron-
idatebased bioresorbable membrane: a prospective,
randomized, double-blind multicenter study. J Am Chem
Soc 1996;183:406407.
31. Fazio VW, Cohen Z, Fleshman JW, et al. Dis Colon
Rectum 2006;49:1161.
32. Nauta RJ. Advanced abdominal imaging is not required to
exclude strangulation if complete small bowel obstructions
undergo prompt laparotomy. J Am Coll Surg 2005;200:
904911.
7
Laparoscopic Surgery
Jay A. Graham, MD and Patrick G. Jackson, MD
INTRODUCTION
Laparoscopy was rst introduced at the beginning of the
19th century. In 1901, George Kelling was the rst to
endoscopically examine the peritoneal cavity, and he called
the procedure koelioscopie.1 In the 1940s, French gyne-
cologist Raoul Palmer used laparoscopy for preoperative
diagnosis and tissue biopsy.2 Throughout the better part
of the 20th century, laparoscopy remained in the hands
of gynecologists. In 1985, Dr. Erich Muhe quietly per-
formed a rudimentary laparoscopic cholecystectomy that
largely went unnoticed. It was not until Dr. Phillipe
Mouret performed what is widely considered to be the
rst laparoscopic cholecystectomy that the surgical com-
munity heralded this procedure.3 The advent of the lapa-
roscopic cholecystectomy opened the door for modern-day
laparoscopic surgery and a revolution soon followed.
Over 750,000 laparoscopic cholecystectomies are per-
formed each year in the United States.4 Whereas this
operation has proved to be the gold standard for gall-
bladder disease, the complexity of operations done lapa-
roscopically continues to be advanced. Although minimally
invasive surgery offers new and often less morbid options
to patients, these procedures can pose signicant risks.
This chapter seeks to outline the major complications in
this burgeoning eld.
INDICATIONS
Need to perform intra-abdominal procedure
OPERATIVE STEPS
Step 1 Induction of general anesthesia
Step 2 Access to peritoneal cavity insufation with CO2
ADVERSE OUTCOMES FOR
ABDOMINAL ACCESS
Initial Abdominal Entry
Although laparoscopic surgery is an exciting mode of
managing surgical problems because it minimizes the
morbidities associated with traditional open approaches,
it can be associated with a higher incidence of intra-
abdominal injury.
Three basic modes of abdominal entry in laparoscopic
surgery are (1) blind insertion of a primary trocar without
creation of a pneumoperitoneum, (2) insertion of the
Veress needle with subsequent establishment of the pneu-
moperitoneum, (3) Hasson technique5; open cutdown
and direct visualization while placing the primary trocar.
All of these techniques are associated with varying degrees
of complications.
Veress needle and trocar injuries account for many of
the injuries seen in laparoscopic surgery. Minor complica-
tions occur during 1.58% of cases, whereas major compli-
cationsincluding bowel perforation, bladder injury,
vascular injury, and abdominal wall hematomaoccur in
0.41% of cases (Figs. 71 to 73).6
Vascular and gastrointestinal injuries are the most trou-
bling aspects of laparoscopic surgery. Although they occur
infrequently, their occurrence can result in signicant
morbidity and even death. Retrospective studies suggest
that major vascular and bowel injuries occur in 0.04% to
0.18% of cases. The Swiss Association for Laparoscopic
and Thoracoscopic Surgery published its nding of an
0.18% incidence after a prospective study of 14,243
patients.7
The initial entry into the abdomen to create the pneu-
moperitoneum is a major cause of bowel injury during
laparoscopic surgery. A review of 40 litigated laparoscopic
cases that resulted in bowel injury demonstrated that many
of these injuries are insidious.8 This delayed recognition is
problematic for both the patient and the physician.
Bowel Injury
Consequence
Trocar injuries are responsible for most of the malprac-
tice claims associated with laparoscopic surgery.9 The
U.S. Food and Drug Administration (FDA) through
its Manufacturer and User Facility Device Experience
(MAUDE) database identied 31 fatal and 1353 non-
fatal injuries associated with trocar insertion from 1997
to 2002. The literature is replete with case reports
detailing solid and hollow viscus organ injuries from
trocars (see Fig. 73).
 98 SECTION I: GENERAL CONSIDERATIONS

Veress Most injuries are presumed to stem from the primary

needle
trocar placement, usually in the umbilical region. This
initial placement is virtually blind, whereas the subse-
quent trocar insertions can be done under direct
visualization.
Optical-access visual obturator trocars were supposed to
provide a safer alternative for primary trocar placement.
These devices are made of clear plastic and allow visualiza-
Abdominal
wall tion of the separation of the abdominal wall layers as they
are inserted. However, even with these instruments, there
Intestines have been documented injuries.10 A study that included
1283 patients showed a 0.31% incidence rate of injury
when using these devices.11
The use of the Veress needle is an alternative to direct
or open trocar insertion. Invented by Dr. Janos Veress in
the 1930s, it was originally used to treat tuberculosis by
creating a pneumothorax, which was the mainstay of treat-
Figure 71 Gastrointestinal injury from Veress needle. ment during this time. A dual needle consisting of a
spring-loaded blunt inner core and a sharp outer sheath
was created because it offered fewer risks of trauma to the
Veress lung. As the Veress needle is placed through soft tissue,
needle the blunt inner needle is displaced and the sharp outer
sheath can cut through tissue. Once the needle is inside
a hollow cavity, the blunt needle springs back into posi-
tion to guard the sharp outer sheath. In the 1970s, the
Veress needle became popular as the eld of laparoscopic
surgery expanded.12
The Veress needle can be used as a substitute for other
Liver methods of establishing a pneumoperitoneum. However,
Aorta
many studies have shown that its use may yield higher
complication rates. Published studies demonstrate that the
Spinal column
Veress needle is more likely to cause minor complications
such as subcutaneous emphysema and extraperitoneal
insufation.13,14 These studies are in line with older studies
that concluded that Veress needle use results in a signi-
cantly higher incidence of minor complications.15,16
Figure 72 Vascular or gastrointestinal injury from Veress However, a great deal of debate exists in the literature
needle. with many reviews concluding that the Veress needle is
a safe alternative to the other entry techniques. A retro-
spective review of 2126 laparoscopic operations, in
which the Veress needle was exclusively used, yielded no
complications.17
Grade 2/3/4 complication

Repair
A study that analyzed laparoscopic injuries that were
reported to the FDA and Physician Insurers Association
of America (PIAA) found that the organ most com-
monly injured is the small bowel. The study also showed
that small and large bowel injuries were the most likely
to go unrecognized in a 24-hour period. Because delay
in recognition can lead to signicant morbidity, the
surgeons suspicions should be heightened if the clini-
cal course deviates from the norm. Moreover, this delay
in treatment has been shown to cause a 26% rate of
Figure 73 Gastrointestinal injury from trocar placement. mortality.18
 7 LAPAROSCOPIC SURGERY 99

Although vascular injuries occur with less frequency

than bowel injuries, the odds of mortality are very high.
The aorta, inferior vena cava, portal vein, and iliac vessels
are all prone to injury from initial trocar placement. In
some thin individuals, the aorta can lie within 5 cm of the
anterior abdominal wall. This underscores a critical element
of laparoscopic surgery in that every attempt should be
made against pushing trocars all the way into the abdomen.
Trocars that are fully advanced to the external cannula are
prone to diving into the retroperitoneum, causing sig-
nicant vascular injury.19
As common sense dictates, recognized injury repair
should be completed during the original operation.
Laparoscopic repair should be attempted unless delay, as
with hemorrhage, may adversely affect the patients
outcome.
Figure 74 Inadequate macrobracing.
Prevention
Although there is no true consensus on the safest tech-
nique for initial abdominal entry, many believe that
open laparoscopic access, as described by Hasson, is the
safest. A retrospective analysis of 5284 patients who
underwent open laparoscopy discovered that only 1
patient suffered a bowel injury.20
In patients with presumed umbilical adhesive disease
from prior abdominal surgery, alternative techniques for
abdominal insufation and entry have been described.
Insufating with a Veress needle placed in the left ninth
intercostal space and primary trocar placement in the left
upper quadrant has been used with low injury rates.21
Placing the initial trocar in this region, specically in the
left midclavicular line 3 cm below the costal margin, has
been advocated by many surgeons as a safe alternative
when umbilical adhesions are suspected.22 Figure 75 Correct macrobracing.
Veress needle insufation should be guided by initial
intra-abominal pressure. In a study of 259 women, initial
pressures lower than 8 mm Hg at 1 L/min ow of CO2 Retroperitoneal Hematoma
demonstrated correct position; pressures greater than The literature offers sparse details on the prevalence
8 mm Hg correlated with interstitial placement.23 of retroperitoneal hematomas caused during abdominal
Abdominal wall lifting has been advocated when laparoscopic procedures. However, one can extrapolate
placing a Veress needle to avoid potential complications. from the penetrating trauma guidelines to help foster
In theory, this technique allows for lifting the abdominal decision making because inadvertent trocar insertion can
wall away from bowel and vasculature. However, this mimic stab wounds (Figs. 76 and 77).
method is associated with an increased number of inser-
tion attempts, which may increase the likelihood of organ Consequence
perforation. The mortality associated with retroperitoneal hemato-
The most consistent means of prevention of trocar mas deserves notice. The trauma literature reports a
placement injuries requires macrobracing (Figs. 74 and mortality of 13%.24 Superior mesenteric artery (SMA)
75). As the trocar is placed in the abdominal wall, the injuries are particularly dangerous to the patient, with
tip will separate the layers of the abdominal wall. Eventu- mortality rates approaching 54%.25
ally, the tip will penetrate the peritoneal cavity, with the Grade 2/3/4 complication
resultant loss of resistance on the trocar. Without bracing
by the nondominant hand, the trocar can damage nearby Repair
structures such as the intestines or retroperitoneal tissues. The abdomen is divided into three zones with respect
By bracing with the nondominant hand, the loss of resis- to retroperitoneal hematomas. Zone I is the centrome-
tance does not result in distribution of force to unwanted dial aspect of the retroperitoneum, lying between the
structures. kidneys and extending from the diaphragmatic hiatus
 100 SECTION I: GENERAL CONSIDERATIONS
Veress
needle
Liver
Aorta
Spinal column
Figure 76 Retroperitoneal vascular injury from Veress needle.
Figure 77 Abdominal wall hematoma from trocar placement
(arrow).
to the inferior vena cava (IVC) bifurcation. Zone II
extends laterally from the kidneys to the paracolic
gutters, and zone III comprises the pelvic region.
Penetrating trauma to zone I should always be explored
because injury in this area can involve major vessels.26
These guidelines should be followed during laparoscopic
surgery. The most likely scenario involves a trocar injury
to the major vessels that course in zone I. If an injury to
a major vessel is found, the surgeon must decide whether
to proceed with ligation, primary repair, or interposition
graft placement.
Penetrating trauma to zones II and III can be managed
without exploration if the patient is stable. A computed
tomography (CT) scan should be obtained to identify the
site of injury. An angiogram may be used to further char-
acterize the hematoma and for therapeutic embolization.
Prevention
Retroperitoneal vascular injury can have devastating
consequences for the patient. Delay in diagnosis can
lead to signicant morbidity and mortality. Therefore,
trocars must be placed under direct vision whenever
possible, and the retroperitoneum should be visualized
prior to exsufation.
Port Site Bleeding
Consequence
Port site bleeding is believed to occur when placement
of a trocar through the abdominal wall lacerates a
branch of the epigastric vessels. Intraoperatively, the
port site bleeding can often be appreciated and con-
trolled. If unrecognized, these bleeds are usually man-
ifested as a hematoma a few days postoperatively. The
incidence of port site hematomas is approximately
6.25%.27
Grade 2/3/4 complication
Repair
Bleeding can be controlled using a variety of methods.
Direct pressure can be placed on the area of concern
using an instrument inserted into another port. Pres-
sure can also be applied using a Foley catheter and
tenting it against the abdominal wall.28 The bleeding
vessel can be cauterized using an instrument that carries
current from the Bovie device. The port site can also
be enlarged to gain control of the bleeding vessel.
Alternatively, by cantilevering the trocar in four direc-
tions, the surgeon can determine in what area the vessel
injury lies and a bolster suture can be placed.29 Lastly,
Surgicel can be pulled through the bleeding port site
to help tamponade the vessel.30
Prevention
All trocars should be pulled out of the body using
direct vision to inspect for bleeding. If bleeding is
encountered, it can be controlled using one of the
methods previously discussed.
PHYSIOLOGIC CONSEQUENCES
As laparoscopic surgery has become more prevalent in the
eld of surgery, it is increasingly important to understand
the challenges of this mode of access to the peritoneal
cavity. In general, the relative contraindications for lapa-
roscopic surgery are related to the physiologic changes
from pneumoperitoneum. For example, patients with
increased intracranial pressure, ventriculoperitoneal shunts,
hypovolemia, and congestive heart failure are ill advised
to have laparoscopic surgery.
Cardiovascular Complications
Laparoscopic surgery performed on patients with cardio-
vascular morbidity should be undertaken with heightened
awareness of the associated risks. Anesthesia as well

has well-documented, potentially deleterious effects on
the cardiovascular system. Thus, in patients who have
signicant cardiovascular morbidity, laparoscopic surgery
can be a relative contraindication owing to stresses of
anesthesia.
The cardiovascular changes that occur during laparo-
scopic surgery are well established, but these rarely have
deleterious effects because of advanced monitoring tech-
niques. Patient positioning and the establishment of the
pneumoperitoneum are the two factors that may cause
signicant cardiovascular strain. Cardiac output is particu-
larly susceptible to the pressures of laparoscopic surgery.
Since the early 1990s, many studies showed that there is
a decrease in cardiac output during various laparoscopic
procedures.31 For example, a 20% to 59% decrease in
cardiac index was detected in 15 nonobese patients during
laparoscopic cholecystectomies.32
Cardiac Output
Patient positions in combination with a pneumoperito-
neum can have detrimental effects because they alter the
normal physiology of venous return.
Consequence
Reverse Trendelenburg positioning and pneumoperito-
neum can limit venous return, which can lead to
decreased preload and subsequent changes in cardiac
output.33 This decrease in cardiac output following
insufation and reverse Trendelenburg has been well
documented.34,35 One study showed a 20% reduction
in cardiac output with 12 mm Hg pneumoperitoneum
and reverse Trendelenburg of 30.36
Grade 1/2 complication
Repair
Laparoscopy requires a multidisciplinary approach
owing to the added physiologic burdens that may occur
during surgery. Feedback from anesthesia is important
and underscores the need for open communication
throughout a case. Cardiopulmonary problems should
prompt the surgeon to level the table and decrease the
pneumoperitoneum until all physiologic issues are
addressed.
Prevention
The role for invasive versus noninvasive cardiac moni-
toring is controversial, and thus, the case is often left
up to clinician judgment. Although there is no clear
consensus regarding placement of these devices, in
patients with cardiac disease, monitoring should
strongly be considered.
Increasing the intravascular volume can help mitigate
the effects of reverse Trendelenburg and intra-abdominal
pressure.37 Insufating the abdomen with the patient in
the horizontal position is also recommended to guard
against a synergistic decrease in cardiac output.38 Lastly,
7 LAPAROSCOPIC SURGERY 101
sequential pneumatic devices have been shown to coun-
teract these hemodynamic changes, and they should be
placed on the patient prior to insufation.39
Cardiac Arrhythmias
The preponderance of cardiac arrhythmias during laparo-
scopic surgery has been described in the literature. It is
generally believed that these arrhythmias occur as a result
of peritoneal stretch receptor mediation via the vagus
nerve during insufation.40 CO2 is also believed to be
proarrhythmic because it can irritate cardiac muscle and
alter conduction pathways.41
Consequence
Bradyarrhythmias and atrioventricular dissociation
during laparoscopic surgery are just some of the more
common arrhythmias described in the literature.42,43
However, during abdominal insufation, the patient is
prone to any type of arrhythmia and must be moni-
tored closely.
Grade 1/2 complication
Repair
Benign arrhythmias such as sinus tachycardia can be
medically managed during surgery. However, more
lethal arrhythmias should be managed expediently
using advanced cardiac life support (ACLS) protocols.
Prevention
Recent studies show that using sequential compression
devices on the lower extremities can decrease the sym-
pathetic response.
Also, helium has been proposed as an alternative to CO2
because it may cause fewer arrhythmias. As of now, further
studies are needed to ascertain which gas is better for
laparoscopy.
Pulmonary Complications
Pneumothorax
Consequence
Pneumothoraces are well-described complications of
laparoscopic surgery.44,45 However, the denitive etiol-
ogy is unclear. A CO2 pneumothorax, sometimes
referred to as a capnothorax, can arise if the peritoneo-
pleural surfaces are violated, allowing CO2 to pass
through the esophageal and aortic hiatuses or through
any diaphragmatic defects. CO2 diffusion into the
pleural space has also been described as a potential
mechanism for the formation of a capnothorax.
Barotrauma from increased airway pressures following
insufation can lead to a bronchopleural conduit that
allows air to enter the pleural space, causing the classic
pneumothorax. Signs that facilitate the diagnosis of a
pneumothorax or capnothorax are a decrease in the partial
pressure of oxygen in arterial blood (PaO2), with an
increase in both the partial pressure of CO2 in arterial
 102 SECTION I: GENERAL CONSIDERATIONS
blood (PaCO2) and the end-tidal carbon CO2 concentra-
tion ETCO2, increased airway pressure, and decreased or
absent breath sounds. A radiograph conrms the sus-
pected diagnosis.
Grade 2/3 complication
Repair
The difference between a pneumothorax and a capno-
thorax is that the latter resolves in a short time follow-
ing exsufation. The high solubility coefcient of CO2
allows for the rapid absorption of CO2 into systemic
circulation. Therefore, follow-up radiographs should
be taken to ascertain whether the lung is expanded. If
the pneumothorax has not resolved and the clinical
situation warrants, a thoracostomy tube should be
placed.
Prevention
Pneumoperitoneum pressures lower than 15 mm Hg
and smaller tidal volumes with positive-pressure
ventilation should be used during laparoscopy to
guard against pneumothorax in patients at risk, such
as those with chronic obstructive pulmonary disease
(COPD).
V/ Q Mismatch and Shunting
It has been shown that insufation transiently decreases
the pulmonary shunt and increases the PaO2.46 However,
this change is eliminated with the continued pneumoperi-
toneum. Insufation of the abdomen elevates the dia-
phragm and decreases the functional residual capacity
(FRC) of the lung.47 This decrease in the FRC can sig-
nicantly alter V/Q pulmonary relationships.
ETCO2 is found to rise with creation of CO2 pneumo-
peritoneum, reaching a plateau level at 30 minutes if
insufation is kept constant.
Consequence
In theory, a decrease in FRC will have a more profound
effect on patients with signicant pulmonary morbidi-
ties than on healthy subjects. Patients with less pulmo-
nary reserve are less able to cope with atelectatic lung
and the resultant shunt.
Grade 1/2 complication
Repair
Positive-pressure ventilation can reverse the decreased
oxygen tension and hypercapnia caused by elevation of
the diaphragm.48 Positive-pressure ventilation decreases
the shunt by increasing the FRC.
Prevention
Increases in the partial pressure of CO2 in alveolar gas
(PACO2) are manifested by hypercapnia and acidosis.
To offset this rise in PACO2, the patient must be hyper-
ventilated to avoid academia. Arterial blood gases
should be assessed as clinically indicated.
Gas Embolism
The literature is replete with incidents of CO2 gas embo-
lism during laparoscopic surgery.4951 This complication is
usually manifested by an abrupt decrease in ETCO2 and
cardiopulmonary collapse.52
Consequence
Even though venous gas embolism has been extensively
reported during laparoscopic hepatic resection, it can
occur during any pneumoperitoneum-based procedure.
Whereas the incidence has been estimated at 15 per
100,000 patients, gas embolism is most likely a common
occurrence that is unrecognized.53,54 This phenomenon
is not usually associated with cardiopulmonary instabil-
ity because CO2 is much more soluble than O2 in
blood.
Grade 1/2 complication
Repair
Cardiovascular resuscitative efforts must begin imme-
diately after the recognition of gas embolism. Evacua-
tion of the pneumoperitoneum should occur rst, and
if at all possible, the patient should be placed in left
lateral decubitus position. If a central line is present, a
syringe may be used to aspirate the gas embolism.
Prevention
In theory, any venous injury in which the central venous
pressure is lower than the pneumoperitoneum can
allow CO2 gas to enter the circulation. Therefore,
central venous pressure should be maintained at an
adequate level and the pneumoperitoneum kept at
minimal settings. The patient should also be hyperven-
tilated to blow off CO2, thereby allowing for rapid
absorption of CO2 into the blood.
Renal Complications
Rhabdomyolysis
Rhabdomyolysis can occur in any postoperative patient
after prolonged operative times. A literature review reveals
that with respect to laparoscopy, this complication is
mainly associated with laparoscopic nephrectomies.
However, one article detailed a 1.4% incidence in gastric
bypass procedures.55
Consequence
Rhabdomyolysis is a well-known phenomenon that
usually occurs in crush injuries and can lead to acute
renal failure because myoglobin precipitates in urine,
leading to nephron injury.
Grade 1/2 complication
Repair
The hallmark of treatment of rhabdomyolysis is
intravenous hydration and alkalization of the urine

to prevent crystallization of myoglobin. The most
common intravenous solution used is 5% dextrose in
water with 3 amps of sodium bicarbonate. Serial cre-
atinine and urine output should be measured to trend
the curves.
Prevention
Every attempt should be made to pad to patient on the
operative bed so as to displace the pressure points. Also,
the use of kidney bumps should be minimized becausse
they may cause muscle ischemia in the ank.56 Postop-
eratively, clinical suspicion for rhabdomyolysis should
be raised in any patient who complains of ank and
gluteal pain. Delay in diagnosis heightens the chance
of the patient developing acute renal failure; therefore,
a creatinine phosphokinase (CPK) level should be
checked immediately. If the CPK is elevated, treatment
should commence immediately.
Hemodynamic Complications
Deep Vein Thrombosis
Changes in venous ow during laparoscopic surgery have
been postulated to contribute an increased incidence of
deep vein thrombosis (DVT).
Consequence
A low-ow venous state in the femoral vein has been
demonstrated during abdominal insufation.57 This
decrease in femoral vein ow may increase the risk for
DVT in the lower extremities.
Grade 1/2 complication
Repair
A patient with a DVT is treated with anticoagulation
therapy to prevent pulmonary embolism.
Prevention
Although there is no clear consensus on the risk of
DVT during laparoscopic surgery, most surgeons place
sequential compression devices on their patients prior
to abdominal insufation. These devices can reverse
venous stasis in the lower extremities and should be
used in patients before establishment of the pneumo-
peritoneum.58
Splanchnic Circulation
Consequence
Increased intra-abdominal pressure caused by insufa-
tion can have profound effects on the splanchnic vas-
culature.59 The splanchnic circulation includes vessels
that supply and drain the abdominal organs. Pneumo-
peritoneum pressures can decrease visceral organ blood
ow through vessel compression.
Grade 1/2 complication
7 LAPAROSCOPIC SURGERY 103
Repair
Patients with laboratory evidence of ischemia or venous
congestion after laparoscopic surgery can be managed
with supportive care.
Prevention
To counterbalance impaired visceral ow caused by
pneumoperitoneum, the intravascular volume should
be optimized to ensure better ow with increased intra-
abominal pressures.
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40. Magrina JF. Complications of laparoscopic surgery. Clin
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41. Bickel A, Kukuev E, Popov O, et al. Power spectral
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expiratory pressure improves arterial oxygenation during
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catastrophic carbon dioxide embolism during laparoscopic
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55. Khurana RN, Baudendistel TE, Morgan EF, et al.
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Section II
BEDSIDE PROCEDURES
Stephen R. T. Evans, MD
All human errors are impatience, a premature breaking off of methodical
procedure, an apparent fencing-in of what is apparently at issue.Franz Kafka

8
Central Vein Catheterization
Michael D. Pasquale, MD, Rovinder S. Sandhu, MD,
Mark D. Cipolle, MD, PhD, and
Dale A. Dangleben, MD

INTRODUCTION
is approximately 15%,5 and as with other technical tasks,
this risk tends to decrease with operator experience.6
In the United States, more than 5 million central vein
Mechanical complications have been reported to occur in
catheters are inserted every year, making it one of the most
5% to 19% of patients, infectious complications in 5% to
commonly performed bedside procedures.1
26%, and thrombotic complications in 2% to 26%.59 The
objective of this chapter is to discuss, in detail, the com-
INDICATIONS
plications associated with central vein access in the hope
that a thorough knowledge of the potential problems will
Unobtainable peripheral venous access or to avoid
result in a decrease in the actual occurrences.
repeated peripheral sticks
Need to deliver high ows of crystalloid, colloid, or
blood products
Central venous pressure measurement or access for
OPERATIVE STEPS
placement of a pulmonary arterial catheter
Administration of sclerosing agents such as chemo-
Step 1 Assess patients need for central venous
therapeutic agents or hyperalimentation
catheterization
Placement of transvenous pacemakers
Step 2 Review patients chart, particularly checking for
Performance of hemodialysis or plasmapheresis
history of coagulation abnormalities and history
Central vein access can be obtained via the jugular, of deep venous thrombosis
subclavian, or femoral vein, and site selection will vary Step 3 Choose appropriate site for placement (i.e.,
depending on why access is being obtained, ease of place- internal jugular, subclavian, or femoral vein)
ment, and associated risks. As with any invasive procedure, Step 4 Obtain consent
risks are associated with central vein catheterization that Step 5 Gather supplies
are both hazardous to patients and costly to treat.24 The Step 6 Perform a time out between the physician and
overall complication rate for central vein catheterization bedside nurse
 108 SECTION II: BEDSIDE PROCEDURES

Step 7 Prep the patientincluding correct patient posi- CENTRAL VEIN ACCESS: SETUP
tioning for particular site
Step 8 Cannulate the vein Prior to the procedure, a number of checks should be
Step 9 Place guidewire performed to ensure that the procedure is completed in
Step 10 Place the catheter over the guidewire the safest and most efcient way. At our institution, a
Step 11 Remove the guidewire Central Line Checklist has been created to ensure that the
Step 12 Aspirate all ports of the catheter appropriate measures for the procedure are considered
Step 13 Flush all ports with saline solution (Fig. 81). This checklist accounts for preprocedure,
Step 14 Secure catheter in place procedure, and postprocedure issues and serves as a
Step 15 Place sterile dressing performance improvement tool as well. The rst step in
Step 16 Conrm placement with radiography if central line placement is to assemble all of the necessary
appropriate materials needed to perform the procedure and complete

INDICATION: Medical Surgical/trauma

PROCEDURE: Elective Emergent/code
CATHETER: TLC SGC Cortis Infuser
SITE: RIGHT Internal jugular Subclavian Femoral
LEFT Internal jugular Subclavian Femoral
RECIDENCY: EM FM IM Surgery OB/GYN
PGY: 1 2 3 4 5 6 Other:

Procedural checklist YES NO

Pre-procedure
Consent obtained (for elective procedures)? If no, give reason:

Confirm landmarks, position patient correctly for procedure?

Assemble equipment/verify supplies?
TIME OUT (check patient ID, announce procedure, including site)?
Abnormal labs checked? (i.e., INR, platelets, etc.)
Sedation used? List meds

Procedure
Cleanse hands
Sterile set up and prep (mask, gown, cap, drape, sterile site)
Inadequate prep due to clinical urgency
If inadequate prep, line placed later
Vein cannulated attempt #1
Vein cannulated attempt #2
Unsuccessful (state reason: )
Assistance called after unsuccessful attempts
Guidewire removed
All ports flushed after good blood draw
Sutured/stapled in place
Use ultrasound/Sonasite
Assisting physician followed same precautions
All staff in room and patient wear masks
Pre-empted by clinical urgency
Aseptic technique maintained throughout procedure
Post-procedure
CXR ordered, reviewed
Complications If yes:
Arterial cannulation Air embolus Cardiac dysrhythmias
Catheter malposition Hematoma Pneumothorax
Uncontrolled bleeding Other:
Attending notified of complications
Previous number of successful central lines by operator

User ID number: Date:

Figure 81 Central venous line procedural checklist.

the tasks outlined in the preprocedure portion of the
checklist.
1. Consent should be obtained after describing the pro-
cedure and the potential complications to the patient
and/or patients guardian. In situations in which con-
sent cannot be obtained, the reason must be clearly
documented.
2. Conrmation of landmarks and proper positioning
of the patient for the procedure should be done.
Depending on the patients underlying medical condi-
tion, one may consider cardiac and oxygen saturation
monitoring.
3. All necessary equipment and supplies should be
veried. Maximal sterile-barrier precautions, including
mask, cap, gown, sterile gloves, and a large sterile drape
should be used because these precautions have been
shown to reduce the rate of catheter-related blood-
stream infections.10
4. Prior to initiating the procedure, a time out should
be performed between the physician and the bedside
nurse. The time out should include verbalizing the
patients name and the procedure to be performed,
including the site of procedure. It should be ensured
that this is the procedure/patient listed on the consent
form. It is recommended that the performance of the
time out be documented.
5. Prior to placement, the chart should be reviewed to
ensure that there are no contraindications to using the
specic site for the central linefor example, if the
patient is coagulopathic, placement in an easily com-
pressible location (e.g., femoral vein) may be chosen to
avoid potential bleeding complications associated with
inadvertent arterial puncture.
6. Consideration should be given for conscious seda-
tion. If it is deemed necessary, appropriate monitoring
should be utilized and medications documented. Some
institutions will require conscious sedation privileges
for the operator, and this should be investigated prior
to using sedative agents.
Preparation is key to the successful completion of central
line placement in a safe and efcient manner.
Internal Jugular Vein Catheterization
In the central approach for internal jugular vein (IJV)
catheterization, the apex of the triangle formed by the two
heads of the sternocleidomastoid muscle and the clavicle
serves as a landmark. The IJV runs deep to the sterno-
cleidomastoid muscle and then through this triangle
before it joins the subclavian vein (SV) to become the
brachiocephalic vein. Right-sided access is typically pre-
ferred because the apical pleura do not rise as high on the
right and one can avoid the thoracic duct. After the land-
marks have been identied, sterile preparation with either
chlorhexidine or povidone-iodine (Betadine) has been
accomplished, and full-barrier precautions have been uti-
8 CENTRAL VEIN CATHETERIZATION 109
lized, local anesthesia (1% lidocaine) is administered and
the patient is placed in head-down 15 Trendelenburg
position with the head rotated 45 away from the side of
cannulation. This position provides for easy landmark
identication and needle insertion as well as allowing for
distention of the vein and prevention of air embolism
during line placement. It is important to remember that
in patients with suspected neck injury, an alternative
approach should be considered to prevent turning of the
patients neck. The patients arm should be straight down
at the side of the body. The physician typically stands at
the head of the bed and places his or her index and middle
nger (of the nondominant hand) on the carotid pulse
and inserts a 22-gauge nder needle through the skin,
immediately lateral to the carotid pulse and slightly supe-
rior to the apex of the triangle. The needle is advanced
past the apex of the triangle, in the sagittal plane 30
posterior and caudad toward the ipsilateral nipple, at an
approximate 50 angle above the frontal plane of the skin.
The needle should be advanced and gently aspirated until
there is free return of venous blood. The IJV is usually
located near the surface of the skin and should be encoun-
tered at or before 3 cm of the needle has been inserted.
If the rst pass is unsuccessful, the needle should be
directed slightly more medially on the next insertion
attempt. With the nder needle in place, an 18-gauge
introducer needle is inserted alongside it and into the vein.
If the nder needle is removed prior to placement of the
introducer needle, care should be taken to ensure the
same course.
Subclavian Vein Catheterization
When utilizing the infraclavicular approach for SV cath-
eterization, note that the SV arises from the axillary vein
at the point where it crosses the lateral border of the rst
rib. The SV is usually 1 to 2 cm in diameter and xed in
position directly beneath the clavicle. It is separated from
the subclavian artery by the anterior scalene muscle. For
catheterization, the patient is placed in 15 to 30 Tren-
delenburg position, and the shoulders are maintained in
neutral or slightly extended position by a small towel roll
placed between the shoulder blades. After identication
of the landmarks (sternal notch, clavicle, deltopectoral
groove), sterile preparation (chlorhexidine or povidine-
iodine), and administration of local anesthesia (1% lido-
caine), the skin is punctured 2 to 3 cm caudal to the
midpoint of the clavicle just lateral to the deltopectoral
groove with an 18-gauge, 2.5-inch introducer needle. A
guide to the puncture site can be created by having the
operator place her or his index nger in the sternal notch
and the thumb of the same hand at the junction of the
medial and middle third of the clavicle, which is typically
in the deltopectoral groove. The needle can be inserted
just lateral and caudal to the operators thumb. The needle
should not be bent and should be advanced parallel to the
clavicle, aiming toward the sternal notch until the tip of
the needle abuts the clavicle at the junction of its medial
 110 SECTION II: BEDSIDE PROCEDURES
and middle thirds. The needle is then passed beneath the
clavicle, with the needle hugging the inferior surface of
the clavicle. During insertion of the needle, slight negative
pressure should be held on the syringe until a ash of
blood is seen. If no blood returns with passage of the
needle, the needle is withdrawn past the clavicle while
gentle suction is applied. Blood return may be achieved
during withdrawal of the needle. If the rst pass is unsuc-
cessful, the needle should be angled in a slightly more
cephalad direction on the next attempt.
The right SV approach is generally preferred because
the dome of the pleura of the right lung is usually lower
than the left, and the thoracic duct is avoided. The left
SV has a sweeping curve to the apex of the right ventricle
and is the preferred approach when placing a temporary
transvenous pacing device.
Femoral Vein Catheterization
When the femoral vein is used for access, the patient
should be positioned supine with the ipsilateral hip slightly
externally rotated. The landmarks that should be identi-
ed prior to beginning include the anterior superior iliac
spine, the pubic tubercle, and the femoral artery. The
femoral arterial pulse will generally be palpated at the
midpoint between the anterior superior iliac spine and
the pubic tubercle. The femoral vein is located medial to
the femoral artery and parallels its course. If the femoral
pulse cannot be palpated, the location of the vein can be
approximated by going two ngerbreadths lateral and two
ngerbreadths caudal to the pubic tubercle.
After identication of the landmarks, sterile preparation
with chlorhexidine or povidone-iodine, and administra-
tion of local anesthesia (1% lidocaine), the skin is punc-
tured below the inguinal crease at a 45 angle aiming
cranially and medial to the femoral pulse. Staying below
the inguinal crease allows for direct compression should
an inadvertent arterial stick occur. An inadvertent arterial
stick above the inguinal ligament can result in retroperi-
toneal hemorrhage that may require operative interven-
tion to control. Typically, the vein should be encountered
by 5 cm of insertion; if it is not, the needle should be
withdrawn slightly while aspirating and redirected later-
ally, taking care to avoid puncturing the femoral artery.
The femoral site is the safest site for the inexperienced
user. In a patient requiring emergent resuscitation, the
femoral approach generally allows swift access while avoid-
ing crowding at the head of the bed.
Seldinger Technique
Once the vein has been accessed, the Seldinger technique
should be utilized to place the catheter. This technique
involves the passage of a soft-tipped guidewire through
the needle and subsequent removal of the needle. After
making a small nick in the skin with a no. 11 scalpel blade,
a dilator is passed over the guidewire, the dilator is
removed, the catheter is passed over the wire, and the wire
is removed. During the passing of the guidewire, the
operator should have the monitor facing him or her. A
common mistake is to pass the wire too far, into the
atrium or ventricle, resulting in arrhythmia.11 Close atten-
tion to patient hemodynamics and oxygen satura-
tion during the procedure is mandatory.
If the vein cannot be accessed after multiple attempts,
stop, reassess, and consult with an experienced operator.
When attempting an internal jugular or subclavian
approach, prior to moving to the contralateral side, a chest
x-ray should be performed to ensure that there is no
evidence of injury, that is, pneumo/hemothorax. One of
the more common complications is failure to cannulate
the central vein. This tends to be a more frequent occur-
rence in the internal jugular and subclavian routes. This
is due, in part, to the fact that central access is blind
and guided by the use of anatomic landmarks, which may
not correlate with vessel location.12 It has been argued
that ultrasound guidance may be useful in situations in
which difcult access is anticipated. Such situations would
include obese patients or those with swollen neck/upper
extremity that would make landmarks difcult to identify,
those who have had multiple central venous catheters
placed and had distorted or thrombosed veins, those
requiring repeated access via the central vein, and those
with coagulopathy.13
Ultrasound Guidance Techniques
Traditionally, the site of initial needle insertion during
central line placement is determined by using palpable or
visible anatomic structures with known relationships to
the desired vein as landmarks.13 However, ultrasound is
increasingly being used to identify vessels and guide needle
insertion when placing central lines. The rst reported use
of Doppler ultrasound to assist with catheter placement
was by Legler and Nugent in 1984.14 Since then, multiple
studies have reported on this technique.12,1520 Several
meta-analyses that reviewed landmark versus ultrasound-
guided IJV central line placement demonstrated signi-
cant relative risk reductions in complications, mean
insertion attempts, and failed catheter insertions when
ultrasound was employed.2123 The results of ultrasound-
guided SV central line placement are not as uniform in
documenting an advantage over landmark techniques.
However, most randomized studies suggest that there is
benet in utilization of ultrasound guidance for the place-
ment of SV catheters.7,12,1520,23
It should be emphasized that this technique is
operator-dependent, and it is recommended that prior to
utilizing this technique, operators undergo both didactic
and hands-on training. During the technique, the ultra-
sound transducer is the component of the ultrasound
system that contacts the patient and is held by the sonog-
rapher. To ensure appropriate imaging and ultrasound
resolution, the highest frequency should be selected to
 8 CENTRAL VEIN CATHETERIZATION 111

maximize denition of the vessel image while maintaining Sternal notch

adequate depth of penetration of the ultrasound signal
(typically 7.5 MHz). Moreover, the ultrasound beam
should be directed essentially perpendicular to the vessel.
In order to cannulate, the vein must rst be visualized
appropriately. With the transducer centered over the vein,
the midpoint should be used for introduction of the access
needle. The needle will appear hyperechoic (white) when
viewed sonographically. Once the vessel has been accessed,
Mastoid Clavicle
the central line is placed as described previously. For IJV
access, the transducer should be placed just cephalad to
the clavicle at the insertion of the two heads of the ster-
nocleidomastoid muscle. For femoral vein access, the
Sternocleidomastoid muscle
transducer is placed a few centimeters distal to the ingui-
nal ligament; for SV access, holding the transducer below Figure 82 Internal jugular vein anatomy.
the clavicle allows for adequate visualization.

PATIENT CHARACTERISTICS
Sternal notch
There are multiple approaches for obtaining central venous
access; however, successful catheterization by any approach
is dependent on a thorough understanding of the anatomy
(Figs. 82 to 84). Whenever the landmarks cannot be
Clavicle
identied for one route of access, another route should
be considered. If central access is needed for resuscitation
from shock, the femoral approach should be considered Sternocleidomastoid
because of the speed and safety with which it can be per- muscle
formed, particularly if the neck landmarks are difcult to
identify or if access to the neck is precluded by other care
providers during the resuscitation.1 Subsequent to the * Note position of index finger at sternal notch.
resuscitation, consideration should be given to changing Figure 83 Subclavian vein anatomy.
the line site because femoral cannulation has been associ-
ated with greater risk of infectious and thrombotic com-
plications.1,58 Nerve and artery
Obtaining a past medical history is very important prior
Inguinal ligament
to line insertion. Patients who have had multiple access
procedures performed in the past (e.g., chronic renal
failure, chemotherapy, intravenous antibiotics), a history
of failed catheterization attempts, the need for catheter- Anterior
ization at a site of previous surgery, skeletal deformity, or superior iliac
spine
scarring secondary to radiation therapy pose a greater
challenge and patient safety dictates that the procedure be
Femoral vein
performed or supervised by an experienced physician.1,7 In
addition, multiple catheterizations can lead to venous ste-
nosis/thrombosis, resulting in difculty accessing the vein
and placing the catheter successfully.24 When such a situ-
ation is encountered, the physician should consider using
uoroscopy and/or ultrasound to aid in the central line
insertion. Pubic
Special consideration should be given to patients who symphysis
have undergone previous thoracic surgery (e.g., lobec-
tomy) because compromise of the good lung (e.g.,
pneumo/hemothorax) may have devastating conse-
quences, whereas placement of a chest tube (if needed
secondary to iatrogenic pneumo/hemothorax) on the side
of previous thoracic surgery can be difcult owing to the Figure 84 Femoral vein anatomy.
 112 SECTION II: BEDSIDE PROCEDURES
presence of intrathoracic adhesions. Patients who have
indwelling central venous devices (e.g., pacemaker, de-
brillator) are unique in that placement of a central line
could disrupt the device and thereby jeopardize the func-
tion. It is imperative that an ample history be taken prior
to performing a central line insertion.
Like prior catheterization attempts and prior surgery/
scarring, patients with low or high body mass index pose
a signicant challenge to central line insertion.2426 Exces-
sive soft tissue, particularly in the supine position, distorts
the usual landmarks and spatial relationships in the neck.
This is most marked when trying to approach the SV
because breast tissue frequently falls toward the clavicle
and should prompt one to consider an alternative approach
or utilize ultrasound for vessel identication.27 In such
cases, it may be necessary to align the puncture site closer
to the sternal notch and more inferior to the clavicle. This
medial approach shortens the distance to the vein and
allows one to ensure that the tip of the needle runs on
the underside of the clavicle. Manual downward traction
on the breast or taping the breasts out of the eld should
also be considered because this will allow for better iden-
tication of landmarks.
A lack of soft tissue such as that seen in cachectic
patients may also contribute to higher morbidity. In these
patients, there tends to be a decreased amount of space
between the clavicle and the rst rib, thus increasing the
risk of pneumothorax.28 Care must be taken during needle
insertion, staying directly on the clavicle, aiming toward
the sternal notch without directing the needle downward
toward the cupula of the lung. The contracted patient
poses a similar challenge when obtaining central venous
access, and it is vitally important to attempt to get the
patients shoulders into a neutral position. If this cannot
be achieved, an alternative site should be considered. A
good technique is to always keep the needle and syringe
parallel to the clavicle and remember that a failed catheter
placement attempt is one of the strongest predictors of
subsequent complication.7
Another alternative for SV cannulation is the supracla-
vicular approach,26,28 but this should be performed only
by an experienced operator familiar with the anatomy and
the technique. Briey, the needle is introduced above the
clavicle at the midpoint of the triangle formed by the
sternal and clavicular heads of the sternocleidomastoid
muscle. The needle should be advanced at a 30 angle
slowly aiming toward the sternum until a ash of venous
blood is obtained. The Seldinger technique is used to
complete the procedure. This approach has been reported
to be safe, with a low complication rate.29
Patients with a history of bleeding disorders or those
on anticoagulants should have a coagulation prole
obtained prior to insertion of a central line. Anticoagula-
tion places the patient at higher risk for hematoma forma-
tion, especially if the subclavian artery is punctured. In
addition, the anatomic location of this vesselposterior
and inferior to the claviclemakes it difcult to control
bleeding by use of external compression. Therefore, if
placement is not urgent, anticoagulation should be cor-
rected prior to inserting the line or an alternative site
should be utilized.
In emergent situations, our personal preference is to
utilize the femoral (rst choice) or internal jugular
approach in anticoagulated patients. Both of these sites
allow for better external compression should bleeding or
inadvertent arterial puncture occur. It is important to
realize that there is no uniform agreement on site selection
in these cases; however, it is also important to understand
the problems that may occur when one does not have
access for compression should bleeding occur.30 Coagu-
lopathy is not an absolute contraindication to SV catheter-
ization; experience and adherence to safe technical
principles are key.
MECHANICAL TECHNICAL
COMPLICATIONS
Mechanical complications are important because their
effects are usually immediate and contribute to increased
hospital length of stay, increased hospital costs, need for
subsequent interventions, and an increased mortality
rate.24 The most common mechanical complications asso-
ciated with central line catheterization include arterial
puncture, hematoma, hemothorax, and pneumothorax.1,24
Other mechanical complications include catheter malposi-
tion and failure to place the catheter, which has been
discussed previously. As shown by McGee and Gould1 and
Eisen and coworkers,24 the incidence of these complica-
tions varies according to the site utilized for catheteriza-
tion. Femoral catheterization is reported to have a higher
incidence of mechanical complications than those of sub-
clavian or internal jugular placement.5
Arterial Puncture
Inadvertent arterial puncture during subclavian line place-
ment is a common occurrence, with an overall reported
incidence in the range of 1% to 13% with 2% to 5% being
typical. This incidence increases to about 40% if multiple
attempts are made.
Consequence
Arterial puncture can lead to hematoma and/or pseu-
doaneurysm formation17 (Fig. 85). The consequences
of subclavian arterial puncture are not as potentially
serious as the consequences of inadvertent internal
carotid artery puncture (e.g., cerebral thromboembolic
event, airway compromise). However, bleeding from
the subclavian artery is much more difcult to control.
In addition, such bleeding may be more easily missed
because the blood may track into the pleural cavity. For
this reason, the subclavian route is generally believed
to be the least suitable approach to the central circula-
tion in the anticoagulated patient. Inadvertent arterial

A
B ulation factors and platelets prior to beginning and to
Figure 85 Mediastinal hematoma post line.
puncture is the reason that all attempts at femoral
central line placement should be done below the level
of the inguinal ligament. This will allow for compres-
sion and prevent retroperitoneal hemorrhage from
inadvertent puncture of the external iliac artery. The
true incidence of subclavian hematoma from catheter
placement has not been reported owing to the difculty
in assessing the location and depth of the vessel in rela-
tion to the clavicle and overlying soft tissue. There are
a few case reports of extrapleural, mediastinal, or soft
tissue hematomas after subclavian line placement;
however, these usually occur in the face of coagulopa-
thy. In addition, both subclavian arteriovenous stula31
and aneurysm32 formation after inadvertent subclavian
arterial puncture have been described.
Grade 1/2 complication
Repair
Fortunately, if the patient is not anticoagulated and the
artery is not dilated, the needle can be removed and
gentle, steady pressure held on the vessel. Patients
having an inadvertent carotid arterial puncture with
8 CENTRAL VEIN CATHETERIZATION 113
resultant expanding hematoma should have their airway
secured and plans should be made for operative inter-
vention. Although percutaneous closure devices have
been successfully used to control bleeding from the
subclavian and femoral vessels, their use in the carotid
artery is not recommended.
In a few circumstances, the blood may track into the
pleural cavity, resulting in the formation of a hemothorax.
After ensuring that the bleeding from the artery has
stopped, any signicant hemothorax should be treated by
placement of a chest tube. If the needle goes through the
vein and the artery, there is long-term risk of developing
an arteriovenous stula or aneurysm. If it is determined
that the line is in the artery, the line should be removed
and pressure applied to the affected artery for approxi-
mately 5 minutes. If the patient is anticoagulated, the
coagulopathy should be corrected prior to removing the
line. At times, this may be done in the operating room or
the interventional radiology suite using a percutaneous
closure device. If the International Normalized Ratio/
partial thromboplastin time (INR/PTT) is normal, the
line can simply be removed at the bedside with appropri-
ate observation for continued bleeding and/or hematoma
development.
Prevention
The most important means of prevention is careful
cannulation of the vein. If one cannot distinguish
venous from arterial blood, a blood gas can be sent
and/or the line can be transduced at the time of can-
nulation.33 It is imperative to know the patients coag-
choose the appropriate puncture site accordingly.
The internal mammary artery arises from the rst part
of the subclavian artery, close to the medial margin of the
scalenus anterior. Thus, it can be argued that an ipsilateral
subclavian approach to the central circulation is contrain-
dicated in patients undergoing internal mammary artery
grafting in case the origin of the internal mammary artery
is damaged. In practice, this does not appear to be the
case, and there are few reports of internal mammary artery
damage complicating subclavian venipuncture.34,35
Pneumothorax
Pneumothorax is one of the most common technical com-
plications of SV and/or IJV catheterization (Fig. 86).
The overall incidence is typically quoted at between 1%
and 2%,36,37 but this increases to about 10% if multiple
attempts at venipuncture are made.38
Consequence
This complication leads to pneumothorax, with the
possibility of impaired respiratory status, or hemody-
namic collapse if a tension pneumothorax develops.
There are frequent reports of delays in the appearance
of a pneumothorax for up to 96 hours after venipunc-
ture,3941 and a meta-analysis by Plewa and Ledrick42
 114 SECTION II: BEDSIDE PROCEDURES
Figure 86 Hinmon pneumothorax.
suggested that delayed pneumothorax complicated
approximately 0.4% of all central venous access attempts,
was much more common after SV than IJV approaches,
was asymptomatic in about 22% of cases, and resulted
in a tension pneumothorax in a similar proportion of
patients. Although rare, in patients with emphysema-
tous disease and multiple blebs, pneumothorax may
result in a large, difcult to control, and life-threaten-
ing air leak.
Grade 1/2/3 complication
Repair
Depending on the size of the pneumothorax, treatment
may range from the administration of oxygen (to
enhance resolution) to formal chest drainage. In the
case of a tension pneumothorax, one must be prepared
to perform needle thoracostomy prior to the tube tho-
racostomy in the presence of hemodynamic collapse. If
concern exists for a bleb puncture and a resultant large
air leak and pneumothorax, the patient should be pre-
pared for emergent thoracotomy.
Prevention
Pnemothorax occurs more commonly in thin patients
and in those with hyperexpanded chests, and it is more
likely if a lateral or supraclavicular approach to the SV
is used, or if the Seldinger needle is allowed to stray
posteriorly during venipuncture. For these reasons, it
is important to obtain a chest x-ray immediately after
placement of an SV or IJV line and to monitor these
patients for possible delayed pneumothorax over the
subsequent 3 to 4 days. Debate continues as to whether
the IJV or SV site has a higher incidence of pneumo-
thorax, but currently, there appears to be no clear
difference.43
Air Embolism
Air embolism is a very rare complication of IJV or SV
catheterization. It has been shown that as little as 20 cc
of air can harm a critically ill patient, but the reported
lethal dose in humans is 100 cc.44,45
Consequnce
Air embolism can lead to difcult oxygenation or
hemodynamic collapse. This complication tends to
occur during insertion of the line when the patient is
in the head-up position and there is negative pressure
in the thoracic cavity (during inspiration).
Grade 1/2/5 complication
Repair
If an air embolism occurs or is suspected, the patient
should be placed in the left lateral decubitus position
while maintaining the head down.46 By doing this, the
air is prevented from owing out of the right ventricle
into the pulmonary artery and can thereby be slowly
reabsorbed or, if deemed necessary, gently aspirated
with a pulmonary artery catheter. Also, patients should
be placed on 100% oxygen; if the previously discussed
methods do not help, hyperbaric oxygen treatment
could be considered.47
Prevention
This complication can be prevented by following the
prescribed technique mentioned earlier in this chapter.
In addition, once the needle is in the vein, the hub
should be occluded at all times to prevent air from
entering the vein. When the catheter is placed, atten-
tion should be directed to each port to conrm that
these are also closed off to the atmosphere. One must
also be wary of this complication during removal of
catheters because air embolism may be more common
during this time.48
Thoracic Duct Injury
Thoracic duct injury is a very rare complication of left-
sided IJV or SV catheterization.
Consequence
It presents either as a chylous leak at the puncture site
along the catheter or as a chylothorax.49,50 The thoracic
duct ends by draining into the posterolateral junction
of the left IJV and SV. The anatomy can be variable
and the duct may enter anterolaterally and therefore be
more prone to injury. The diagnosis is conrmed by
sending the uid for triglyceride analysis and lympho-
cyte count.49,50
Grade 1/2/3 complication
Repair
Most of these injuries will respond to conservative man-
agement such as chest tube placement and hyperali-
mentation.50 If the patient fails conservative therapy,
thoracic duct ligation may be required.49

Prevention
Avoidence of left SV or left IJV approach. However,
the incidence of this complication is rare, so left-sided
central venous cannulization is not contraindicated.
Arrythmia
Close attention to patient hemodynamics and oxygen
saturation during the procedure is mandatory. One small
prospective study showed 41% of central vein catheteriza-
tions resulted in atrial arrhythmias and 25% produced
some degree of ventricular ectopy.11
Consequence
This is generally transient and resolves once the wire
is slowly withdrawn. If the patient is not monitored,
this could go unnoticed and result in a potentially fatal
arrhythmia.
Grade 1 complication
Repair
Treatment is to slowly withdraw the guidewire. No
long-standing morbidity or mortality resulted from
these arrhythmias.11 Rarely, one must consider admin-
istering antiarrhythmic agents.
Prevention
Arrhythmias are difcult to prevent; however, close
monitoring of the patient will keep this complication
relatively benign.
Guidewire Loss
One hand should be kept on the guidewire at all times to
prevent inadvertent loss of the wire into the central vein.
Loss of the guidewire (Fig. 87) usually happens in an
unsupervised situation when the operator does not advance
the guidewire the whole way through the catheter prior
to placing the catheter through the skin and thus advances
the catheter with the wire in it into the central vein.
Figure 87 Chest x-ray shows guidewire loss and migration after
placement of femoral central venous line.
8 CENTRAL VEIN CATHETERIZATION 115
Consequence
The guidewire could migrate into the heart or the IVC.
There have been a few case reports of the guidewire
getting caught in an IVC lter.5153
Grade 1/2 complication
Repair
If this complication occurs, the patient should be
taken immediately to interventional radiology and
the wire removed under direct uoroscopy. If the
guidewire becomes caught in the IVC lter, a hemo-
stat should be placed on the guidewire at the skin
level and the patient should be taken to the interven-
tional radiology suite. Under uoroscopy, the guide-
wire can be carefully released and pulled out and an
alternative site planned for placement of the central
line.
Prevention
Proper technique and supervision should prevent most
guidewire losses. If a patient is known to have an IVC
lter, central line placement should be performed under
uoroscopy to avoid the wire being caught in the lter
and damaging or malpositioning the lter.
Cardiac Perforation
Cardiac perforation with associated pericardial tamponade
during central vein catheterization has been reported (Fig.
88) but is extremely rare thanks to efforts put forth by
the U.S. Food and Drug Administration and the catheter
companies.
Consequence
It is important that physicians be aware of this compli-
cation as well as the potential for catheter erosion and
subsequent development of pericardial tamponade
because the condition is often lethal.52 In a 1998 ret-
rospective review of 25 cases of cardiac tamponade
from central venous catheterization, it was noted that
all postinsertion chest radiographs showed the tip of
the catheter to be within the pericardial silhouette, and
all patients developed unexplained hypotension from
hours to 1 week after central line placement. Other
associated signs included chest tightness (8 patients),
shortness of breath (12 patients), air hunger (15
patients), and inferior wall injury shown by electrocar-
diogram (7 patients).54 This and several other articles
suggest that this complication can be prevented and the
outcome improved if the signs previously discussed are
investigated promptly.5457
Grade 3/4/5 complication
Repair
If patient develops a pericardial tamponade, the best
chance of survival is early recognition and surgical
repair. Unfortunately, it is often not discovered in time
and the outcome is often poor.
 116 SECTION II: BEDSIDE PROCEDURES
A The prevalent organism is coagulase-negative staphylo-
B Disease Control and Prevention denitions of blood-
Figure 88 A, Cardiac tamponade resulting from perforation
of the right ventricle with central line guidewire. B, Postmortem
view of perforation of right ventricle secondary to central line
guidewire.
Prevention
Always use the J-wire provided in most commercially
available central access kits. Avoid using stiffer guide-
wires without the assistance of uoroscopy. Place the
catheter in the proximal superior vena cava, avoiding
placement within the cardiac silhouette.
Other
Interestingly, there have been case reports of spinal acces-
sory nerve injury as a complication of IJV cannulation.58
Injuries to the brachial plexus and vagus and phrenic
nerves have also been documented.5962 These nerve inju-
ries are very rare, and a better understanding of neck
anatomy will reduce their incidence.
CATHETER PROBLEMS
Catheter Infection
Consequence
Catheter infection is the most common complication
related to central line insertion, and the progression of
line infection to line sepsis increases morbidity and
mortality.63 A central line can become infected at the
puncture site via migration of the pathogen along the
catheter and also by hematogenous seeding of the cath-
eter.1 The most common way that catheters become
infected is migration of skin organisms at the puncture
site into the catheter tract, resulting in the colonization
of the tip of the catheter.64
Grade 1 complication
Treatment
Treatment of catheter-associated infection involves
removing the catheter and administering antibiotics.
coccus, which has a high rate of resistance to methicil-
lin. One must keep this in mind prior to beginning
antimicrobial agents for presumed line infections and
line sepsis.
Prevention
Although emergency situations exist in which central
venous catheterization is done under substerile condi-
tions, it cannot be overemphasized how important
maximal barrier precautions and technique are to pre-
venting catheter site infection and catheter-related
sepsis.10
It is recommended that there be institutional tracking
of central lineassociated infections using the Centers for
stream infection, catheter infection, and colonization. In
the setting of strict sterile technique with insertion by
experienced operators, a prospective, observational study
showed that SV, IJV, and femoral catheter sites have
similar risks of catheter infection.65 Other studies, however,
suggest that femoral vein and IJV catheterization are
associated with a higher infection rate.5,66,67 As mentioned
previously, the best way to reduce infection risk with
central line placement is strict adherence to sterile proto-
col, placement by experienced operators, and catheter
maintenance by trained nurses.65
Antibiotic administration prior to central line insertion
is not recommended and should be discouraged because
of the increased risk of developing antibiotic resistance.68
In immunocompromised patients, however, several studies
have shown that antibiotic use decreased catheter-related
infection.69,70 The use of antimicrobial-impregnated cath-
eters has been studied, but to date, the results are conict-
ing and there is no general consensus as to whether they
should be used on a routine basis.8,71
Catheter-Related Venous Thrombosis
Consequence
Catheter-related venous thrombosis is related to both
venous injury caused by line placement and the pres-
ence of a foreign body within the vein. The presence
of a central vein catheter is the greatest independent
predictor of upper extremity deep vein throm-

bosis, increasing the risk sevenfold.72 Central venous
thrombosis may result in swelling of the ipsilateral
extremity, clot embolization, and infection. The
reported rates of catheter-related central venous throm-
bosis varies (33% in one series) and may differ by
site selection.5,7274 However, the overall incidence of
symptomatic catheter-related thrombosis ranges from
0% to 4%.75
Grade 1/2 complication
Treatment
If there are any clinical signs or symptoms of central
vein thrombosis such as ipsilateral swelling and pain, a
venous duplex should be performed. After the central
line is removed, anticoagulation remains the mainstay
for central vein thrombosis to prevent clot propagation.
The risk of clinically signicant pulmonary embolism
related to central vein catheter thrombosis is approxi-
mately 5%.76
Prevention
Although little can be done to prevent catheter-related
thrombosis, vigilance in inspecting the site and extrem-
ity may lead to earlier diagnosis and treatment.
Other
There have been a few case reports of catheter emboliza-
tion (grade 2/3/4), which generally result from a distal
fracture in a long-term catheter.7779 Although this is rare,
it should be recognized as life-threatening and addressed
immediately. Radiographic localization and interventional
radiographic extraction techniques are generally required
for retrieval.
Catheter occlusion (grade 1) is another common com-
plication of central venous access. There are many ways in
which a central catheter may become occluded including
occlusion by the brin sheath that forms around the cath-
eter, intraluminal or mural thrombus formation, and
injury to the venous endothelium. If the catheter becomes
occluded, patency can be restored at times by use of a
brinolytic agent. These agents act by activating plas-
minogen to form plasmin, which degrades brin. Alteplase
(tissue plasminogen activator [t-PA], 0.52 mg) is the
approved agent/dose for clearing a clotted catheter.
SUMMARY
In summary, complications of central venous access can
be minimized by
1. Performance of an ample history.
2. Acquiring a detailed knowledge of central venous anat-
omy and the anatomy of surrounding structures.
3. Adherence to maximal barrier precautions and sterile
technique.
4. Knowledge of potential complications.
5. Development of a procedural protocol.
8 CENTRAL VEIN CATHETERIZATION 117
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complications of central venous catheters. J Intensive Care
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25. Lefrant J, Muller L, De La Coussaye M, et al. Risk factors
and immediate complication of subclavian vein catheter-
ization in critically ill patients. Intensive Care Med
2002;28:10361041.
26. Nevarre DR, Domingo OH. Supraclavicular approach to
subclavian catheterization: review of the literature and
results of 178 attempts by the same operator. J Trauma
1997;42:305309.
27. Haire WP, Lieberman RP. Dening the risks of subcla-
vian-vein catheterization. N Engl J Med 1994;331:1769
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28. Helmkamp BF, Sanko SR. Supraclavicular central venous
catheterization. Am J Obstet Gynecol 1985;153:751754.
29. Muhm M, Sunder-Plassmann G, Apsner R, et al. Supracla-
vicular approach to the subclavian/innominate vein for
large-bore central venous catheters. Am J Kidney Dis
1997;30:802808.
30. Foster PF, Moore LR, Sankary HN, et al. Central venous
catheterization in patients with coagulopathy. Arch Surg
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31. Ricol F, Valiente E, Bodson F, et al. Arteriovenous
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32. Huddy SPJ, McEwan A, Sabbat J, Parker DJ. Giant false
aneurysm of the subclavian artery. Anaesthesia 1989;44:
588589.
33. Oliver WC Jr, Nuttall GA, Beynen FM, et al. The
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34. Kulkarni R, Moreyra AE. Left internal mammary artery
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35. Morand P, Masson D, Charbonnier B, et al. Iatrogenic
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36. Sise MJ, Hollingsworth P, Brimm JE, et al. Complications
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37. Patel C, Laboy V, Venus B, et al. Acute complications of
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vein cannulation attempts must be stopped? Presented at
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Suppl B, Abstract B11, September 1998.
39. Plaus WJ. Delayed pneumothorax after subclavian vein
catheterization. J Parenter Enteral Nutr 1990;14:414
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40. Sivak SL. Late appearance of pneumothorax after subcla-
vian venipuncture. Am J Med 1986;80:323324.
41. Spiliotis J, Kordossis T, Kalfarentzos F. The incidence of
delayed pneumothorax as a complication of subclavian
vein catheterisation. Br J Clin Pract 1992;46:171172.
42. Plewa MC, Ledrick D. Delayed tension pneumothorax
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pressure ventilation. Am J Emerg Med 1995;13:532
535.
43. Ruesch S, Walder B, Tramr MR. Complications of
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44. Kashuk JL, Penn I. Air embolism after central venous
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46. Flanagan JP, Gradisar IA, Gross RJ, Kelly TR. Air
embolusa lethal complication of subclavian venipunc-
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cerebral air embolism: importance of an early hyperbaric
oxygenation. Intensive Care Med 2002;28:559563.
48. Heckmann JG, Lang CJ, Kindler K, et al. Neurologic
manifestations of cerebral air embolism as a complication
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16211625.
49. Khalil KG, Parker FB Jr, Mukherjee N, Webb WR.
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51. Chattar-Cora D, Tutela RR Jr, Tulsyan N, et al. Inferior
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463468.
52. Duong MH, Jensen WA, Kirsch CM, et al. An unusual
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53. Yengul TN, Bonilla SM, Goodwin SC, et al. Retrieval of a
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54. Collier PE, Blocker SH, Graff DM, Doyle P. Cardiac
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55. Collier PE, Goodman GB. Cardiac tamponade caused by
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56. Collier PE, Ryan JJ, Diamond DL. Cardiac tamponade
from central venous catheters. Report of a case and
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57. Burns S, Herbison GJ. Spinal accessory nerve injury as a
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58. Chabanier A, Dany F, Brutus P, Vergnoux H. Iatrogenic
cardiac tamponade after central venous catheter. Clin
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59. Depierraz B, Essinger A, Morin D, et al. Isolated phrenic
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60. Paschall RM, Mandel S. Brachial plexus injury from
percutaneous cannulation of the internal jugular vein. Ann
Emerg Med 1983;12:5860.
61. Sylvestre DL, Sandson TA, Nachmanoff DB. Transient
brachial plexopathy as a complication of internal jugular
vein cannulation. Neurology 1991;41:760.
62. Vest JV, Pereira MB, Senior RM. Phrenic nerve injury
associated with venipuncture of the internal jugular vein.
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63. Pittet D, Wenzel RP. Nosocomial bloodstream infections.
Secular trends in rates, mortality, and contribution to
total hospital deaths. Arch Intern Med 1995;155:1177
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64. Mermel LA, McCormick RD, Springman SR, Maki DG.
The pathogenesis and epidemiology of catheter-related
infection with pulmonary artery Swan-Ganz catheters: a
prospective study utilizing molecular subtyping. Am J
Med 1991;91(suppl):S197S205.
65. Deshpande KS, Hatem C, Ulrich HL, et al. The incidence
of infectious complications of central venous catheters at
the subclavian, internal jugular, and femoral sites in an
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1320; discussion 234235.
66. Norwood S, Wilkins HE III, Vallina Van L, et al. The
safety of prolonging the use of central venous catheters:
a prospective analysis of the effects of using antiseptic-
bonded catheters with daily site care. Crit Care Med
2000;28:13761382.
67. Richet H, Hubert B, Nitemberg G, et al. Prospective mul-
ticenter study of vascular-catheterrelated complications
and risk factors for positive central-catheter cultures in
8 CENTRAL VEIN CATHETERIZATION 119
intensive care unit patients. J Clin Microbiol 1990;28:
25202525.
68. Hospital Infection Control Practices Advisory Committee
(HICPAC). Recommendations for preventing the spread
of vancomycin resistance. Infect Control Hosp Epidemiol
1995;16:105113.
69. Bock SN, Lee RE, Fisher B, et al. A prospective random-
ized trial evaluating prophylactic antibiotics to prevent
triple-lumen catheter-related sepsis in patients treated with
immunotherapy. J Clin Oncol 1990;8:161169.
70. Henrickson KJ, Axtell RA, Hoover SM, et al. Prevention
of central venous catheterrelated infections and throm-
botic events in immunocompromised children by the use
of vancomycin/ciprooxacin/heparin ush solution: a
randomized, multicenter, double-blind trial. J Clin Oncol
2000;18:12691278.
71. Dunser MW, Mayr AJ, Hinterberger G, et al. Central
venous catheter colonization in critically ill patients: a
prospective, randomized, controlled study comparing
standard with two antiseptic-impregnated catheters.
Anesth Analg 2005;101:17781784.
72. Joffe HV, Kucher N, Tapson VF, Goldhaber SZ. Upper
extremity deep vein thrombosis: a prospective registry of
592 patients. Circulation 2004;110:16051611. Epub
2004;September 7.
73. Durbec O, Viviand X, Potie F, et al. Lower extremity
deep vein thrombosis: a prospective, randomized, con-
trolled trial in comatose or sedated patients undergoing
femoral vein catheterization. Crit Care Med 1997;25:
19821985.
74. Timsit JF, Farkas JC, Boyer JM, et al. Central vein
catheterrelated thrombosis in intensive care patients:
incidence, risk factors, and relationship with catheter-
related sepsis. Chest 1998;114:207213.
75. Lowell JA, Bothe A Jr. Venous access. Preoperative,
operative, and postoperative dilemmas. Surg Clin North
Am 1991;71:12311246.
76. Hingorani A, Ascher E, Markevich N, et al. Risk factors
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476478.
77. Nazareno J, Elliott JA, Finnie KJC. Cardiac arrhythmia
due to subclavian catheter fracture and embolization. Can
J Cardiol 2005;21:791792.
78. Peskin B, Soudack M, Ben-Nun A. Hickman catheter
rupture and embolizationa life-threatening complica-
tion. Isr Med Assoc J 1999;1:289.
79. Roggla G, Linkesch M, Roggla M, et al. A rare complica-
tion of a central venous catheter system (Port-a-Cath). A
case report of a catheter embolization after catheter
fracture during power training. Int J Sports Med 1993;14:
345346.
9
Pulmonary Artery Catheterization
Rovinder S. Sandhu, MD and
Michael D. Pasquale, MD

INTRODUCTION Management of multiorgan system failure and/or

severe burns
Pulmonary artery catheterization (PAC) has been the Management of hemodynamic instability after cardiac
subject of enormous controversy regarding its utility since surgery
its introduction by Swan and Ganz and coworkers in Assessment of response to treatment in patients with
1970.1 Detailed discussion regarding this controversy is primary pulmonary hypertension
beyond the scope of this chapter. However, a study per- Aspiration of air emboli
formed by Connors and colleagues in 19962 comparing
outcomes of critically ill patients managed with or without In addition, PAC may be useful in perioperative
a PAC within the rst 24 hours after admission to an monitoring of high-risk patients undergoing high-risk
intensive care unit (ICU) revealed an association between procedures.
PAC and an increased relative risk of hospital mortality As with any other invasive procedure, PAC has its
and increased utilization of resources. This paper reignited own inherent technical complications during insertion.
the controversy and made clinicians reevaluate the efcacy The overall risks of complications have been reported
and safety of the pulmonary artery (PA) catheter. Many to be anywhere from 5% to 15%. These include complica-
studies show no benet or harm from PAC35; others show tions related to venous access and to right heart catheter-
decreased mortality.6,7 Amid the controversy, physicians ization and PAC as well as infectious and thrombotic
continue to use PAC in critically ill patients, although no complications.10
validated indications exist for its use.
PA catheters are used to provide various hemodynamic
parameters. Directly measured data include heart rate, OPERATIVE STEPS
waveforms, cardiac output, pulmonary artery pressures,
right atrial pressure (central venous pressure [CVP]), Step 1 Assess patients need for pulmonary artery
pulmonary arterial occlusion pressure (PAOP; wedge), catheterization
and mixed venous oxygen saturation. In addition, using Step 2 Review patients chartparticularly checking for
these parameters, many other valuesincluding mean history of coagulation abnormalities and history
arterial blood pressure, body surface area, stroke volume, of deep venous thrombosis
systemic and pulmonary vascular resistance, ventricular Step 3 Choose appropriate site for placement (i.e.,
stroke work, and oxygen delivery and consumptioncan internal jugular or subclavian)
be calculated.8 Step 4 Obtain consent
Step 5 Gather supplies
Step 6 Perform a time out between the physician and
INDICATIONS 9 bedside nurse
Step 7 Prep the patientincluding correct patient posi-
Diagnosis of shock states tioning for particular site
Differentiation of high- versus low-pressure pulmonary Step 8 Cannulate the vein
edema Step 9 Place guidewire
Diagnosis of primary pulmonary hypertension Step 10 Place the cordis over the guidewire
Diagnosis of valvular disease, intracardiac shunts, Step 11 Remove the guidewire
cardiac tamponade, and pulmonary embolus Step 12 Aspirate blood from the cordis
Monitoring and management of complicated acute Step 13 Flush the cordis
myocardial infarction Step 14 Flush the ports of the pulmonary artery
Assessment of hemodynamic response to therapies catheter
 122 SECTION II: BEDSIDE PROCEDURES
Step 15 Attach catheter to transducer and check fre-
quency response
Step 16 Place pulmonary artery catheter through the
cordis to 20 cm
Step 17 Inate balloon and follow until a pulmonary
artery occlusion tracing is identied
Step 18 Deate balloon and identify pulmonary artery
tracing
Step 19 Secure catheter
Step 20 Place sterile dressing
Step 21 Check placement with chest x-ray
OPERATIVE PROCEDURE
Prior to placing a PA catheter, one must obtain all neces-
sary equipment and review the patients chart.
1. Informed consent should be obtained from the patient
or power of attorney.
2. Review the patients chart to make certain no contra-
indications exist (e.g., coagulopathy, tricuspid or pul-
monary valve mechanical prosthetics, right heart mass,
tricuspid or pulmonary valve endocarditis, history of
heparin-induced thrombocytopenia [many PA cathe-
ters are heparin-coated; non-coated ones are available],
and history of left bundle branch block).
3. An experienced nurse should be available and in the
room to assist with the procedure, along with a physi-
cian experienced in PAC and waveform analysis.
4. All necessary equipment should be gathered including
introducer sheath, PA catheter, transducers, and ushes.
In addition, as in central vein catheterization, maximal
sterile-barrier precautions should be used (mask, cap,
gown, sterile gloves, and a large sterile drape).
5. Although most patients are critically ill or in the operat-
ing room while having a PA catheter placed, appropri-
ate sedation and local anesthetic should be used.
The rst step in PAC is to obtain venous access. A PA
catheter can be introduced most commonly through
internal jugular, subclavian, and femoral sheath intro-
ducers. If needed, the external jugular vein or antecubital
fossa can be used. Each site has specic risks. Review
Chapter 8, Central Vein Catheterization, for insertion of
introducer sheaths and complications in accessing these
sites. Each site has its own advantages and disadvantages
for subsequently placing a PA catheter.
1. Internal jugular vein
a. Lower risk of pneumothorax.
b. Right-sided offers the most direct approach to the
heart.
c. Left-sided offers a less direct approach to the heart
and may make achieving a PAC more difcult.
d. Risk of carotid puncture and dilation with a large-
bore sheath introducer may lead to cardiovascular
accident or neck hematoma and loss of airway.
2. Subclavian vein
a. Higher risk of pneumothorax.
b. Usually high rate of successful PAC in right- or left-
sided placements.
c. Subclavian arterial puncture may be more difcult
to control, especially in coagulopathic patients, and
may lead to hemothorax.
3. Femoral vein
a. No risk of pneumothorax.
b. Arterial puncture is easier to control with pressure,
although peripheral embolization is of concern.
c. Difcult PAC; uoroscopy may be useful.
d. History of internal jugular vein catheterization lter
is an absolute contraindication.
4. External jugular and antecubital approaches
a. Usually require uoroscopy.
b. Difcult for PAC, although published rates of success
are in excess of 75%.11,12
c. Higher rates of thrombosis in peripheral veins.
Complications of central vein catheterization are dis-
cussed in Chapter 8, Central Vein Catheterization. These
include pneumothorax, hemothorax (grade 2), thoracic
duct injury (grade 2/3), arterial puncture, possible pseu-
doaneurysm formation or arteriovenous stula formation
(grade 1/2/3), air embolism (grade 2/5), cardiac perfo-
ration with associated cardiac tamponade (grade 3/4/5),
thrombus (grade 1/2/5), and infections (grade 1).
Once central vein catheterization is achieved, one can
prepare for PAC. Many different PA catheters exist; they
all have some similarities (Fig. 91):
1. Yellow portPA port
2. Blue portCVP port
3. Pink port1.5-cc balloon port
4. Clear portinfusion port (if available)
5. PA catheter marked at 10-cc intervals for monitoring
placement
Figure 91 Pulmonary artery catheter.
 9 PULMONARY ARTERY CATHETERIZATION
In addition to these general guidelines, specialized cath-
eters are increasingly available. These include pacing PA
catheters, right ventricular function catheters, continuous
cardiac output catheters, and oximetric catheters for con-
tinuous mixed venous oxygen saturation monitoring.
Prior to oating the catheter, the following must be
done:
1. All ports are ushed.
2. Catheter is placed through a sterile sheath to allow
future adjustments.
3. Balloon is checked by inating air to 1.5 cc.
4. PA port is connected to a pressure transducer.
5. Frequency response of the transducer is checked by
moving the tip to see an appropriately changing wave-
form on the monitor.
6. All catheters are manufactured with a natural curve.
Curve should be adjusted to allow for easier ow
through the right ventricular outow tract.
7. If patient was placed in Trendelenburg position for
venous access, he or she should be leveled or placed
slightly head up.
Next, the PA catheter is ready for insertion. One must
be aware of the characteristic waveforms as the catheter
advances to the PA.
1. Place catheter to 20 cm, then inate balloon (never
advance catheter with balloon down).
2. With balloon inated, advance as the waveform changes
from a CVP pattern to a right ventricular pattern. This
is characterized by systolic pressure 15 to 30 mm Hg
and diastolic pressure approximating right atrial (CVP)
pressure 0 to 5 mm Hg.
3. Continue advancement to the PA as evidenced by
the identication of a dicrotic notch and a higher
diastolic pressure: normally 15 to 30 mm Hg systolic, 8
to 12 mm Hg diastolic.
4. Careful, slow advancement will lead to PA occlusion
pressure which approximates PA end-diastolic pressure
(812 mm Hg).
5. At this point, the balloon should be deated and the
PA tracing should once again be identied; if not, the
balloon should be withdrawn slightly and readvanced
to PA occlusion.
6. Obtain chest x-ray to look for placement.
If the appropriate tracings are unable to be identied,
the catheter should be withdrawn, with the balloon down,
to 20 cm and readvanced. A study by Tempe and associ-
ates13 showed approximate insertion lengths in patients
undergoing cardiac surgery. They found, from a right
internal jugular approach, that the right ventricle is reached
at 24.6 cm (95% condence interval [CI] 24.224.9), the
pulmonary artery at 36 cm (95% CI 35.636.5), and pul-
monary artery occlusion at 42.8 cm (95% CI 42.2
43.5 cm). Although PAC varies with different routes of
123
insertion, patients, and pathology, one should keep these
approximate lengths in mind. If the catheter is being
advanced past 60 cm without a right ventricle, PA, or
wedge tracing, it is necessary to reevaluate and consider
obtaining a chest x-ray or readvancing the catheter because
the risk of coiling or improper placement increases.
COMPLICATIONS OF PULMONARY
ARTERY CATHETER FLOTATION
Arrhythmia
Arrhythmias are the most common complication during
PAC, occurring in up to 87% of patients. However, they
are often short-lived and benign. Certain patient popula-
tions have a higher incidence of arrhythmias such as myo-
cardial infarction, myocarditis, hypokalemia, hypoxia, and
acidosis.14
Consequence
Atrial ectopic beats, ventricular tachycardia, ventricular
brillation, right bundle branch block, or complete
heart block may occur; most are short-lived and recover
spontaneously. Ventricular tachycardia requiring treat-
ment occurs in approximately 1% of catheterizations.
Right bundle branch block occurs in 0.5% to 5%, and
in the presence of a left bundle branch block, a com-
plete heart block may occasionally occur.8
Grade 1/2 complication
Repair
Upon recognition of an arrhythmia, back up the cath-
eter and reoat. If the arrhythmia continues, adminis-
tration of lidocaine or other antiarrythmic agent may
be necessary. Occasionally, transvenous or transdermal
pacing is required.
Prevention
If the patient has risk factors for arrhythmia, appropri-
ate medications should be nearby. If a preexisting
left bundle branch block is present, consider a transve-
nous pacing PA catheter versus being prepared for
transcutaneous pacing. However, because the risk of
complete heart block in the presence of left bundle
branch block is less than 1%, prophylactic pacing is not
warranted.15 Prophylactic lidocaine may decrease the
incidence of mechanically induced arrhythmias.16
Decreased catheterization times also may lead to fewer
arrhythmias.17
Coiling of Pulmonary Artery Catheter
PA catheters are responsible for two thirds of coiled intra-
vascular devices. This complication results most often
from looping of the catheter in the right ventricle, but it
can become knotted in the vena cava or PA. Occasionally,
it can result in looping around intracardiac structures
(papillary muscles or tricuspid valve).18
 124 SECTION II: BEDSIDE PROCEDURES
Figure 92 Chest radiographic lm shows the knotted (encircled)
pulmonary artery catheter xed in the superior vena cava.
(Reprinted with permission from Georghiou GP, Vidne BA, Raanani
E, et al. Knotting of a pulmonary artery catheter in the superior
vena cava: surgical removal and a word of caution. Heart 2004;90:
e28; BMJ Publishing Group Ltd.)
Figure 93 Knot in the removed pulmonary artery catheter.
(Reprinted with permission from Georghiou GP, Vidne BA, Raanani
E, et al. Knotting of a pulmonary artery catheter in the superior
vena cava: surgical removal and a word of caution. Heart 2004;90:
e28; BMJ Publishing Group Ltd.)
Consequence
If the catheter becomes knotted, it will not be able to
be removed and will not function properly. The mortal-
ity rate in one study was 8%18 (Figs. 92 and 93).
Grade 2/3/5 complication
Repair
Initially, interventional radiologic approaches are used
to aid in removal. Various techniques have been
described, including untying the knot under uoros-
copy with the use of guidewires or balloon catheters.
Other techniques involve tightening the knot under
uoroscopic control in order to remove it with the
introducer sheath.19
If the coil is large and contains many loops, surgical
removal is required. Most commonly, this is a combined
procedure with interventional radiology, in which the
catheter knot is guided to a more accessible location such
as the internal jugular vein and removed through a venot-
omy.20 If the catheter becomes xed to an intracardiac
xture, open heart surgery may be required for removal.
Prevention
The most important concept in preventing this com-
plication is to avoid excessive catheter length prior to
encountering PA pressures or a wedge tracing. In addi-
tion, looping may be suspected if multiple ventricle
ectopia are seen. In both cases, the catheter should be
withdrawn to the 20-cm mark and reoated.
Pulmonary Artery Rupture
Consequence
PA rupture is a relatively rare event; however, it is the
most serious complication arising from otation of a
PA catheter. The incidence ranges from 0.03% to 0.2%
with a mortality rate of 50% to 70%.21 Risk factors for
rupture include female gender, advanced age over 60
years, anticoagulation, pulmonary hypertension, balloon
hyperination, steroid use, multiple and frequent cath-
eter manipulation, peripheral placement of the catheter,
and inating the balloon with uids other than air. In
addition, surgically induced hypothermia and cardiac
decompression and manipulation during cardiac surgery
may increase the risk for rupture.10
PA rupture leads to hemorrhage, pseudoaneurysm
formation, hemoptysis, hypoxia, and hemodynamic insta-
bility. Pseudoaneurysm may be discovered in a delayed
fashion days to months or years after removal of a PA
catheter and can be identied as an incidental nding of
imaging studies (Figs. 94 to 96).
Grade 25 complication
Repair
The management of PA rupture depends largely upon
two factors: location of the patient (i.e., operating
room, ICU, or outpatient setting) and the presence of
hemodynamic instability. If the patient is in the operat-
ing room undergoing cardiac surgery, the rupture is
often repaired directly and may include direct repair of
the PA, ligation, or lobectomy or pneumonectomy,
depending on the degree of hemorrhage and hemody-
namic stability. If the patient is not undergoing cardiac
surgery and PA rupture is entertained, transcatheter
embolization should be performed, if possible.
If the patient is in the ICU or an outpatient setting, a
pulmonary angiogram should be performed to diagnose
the site of bleeding and denitively treat the lesion. A
high index of suspicion must be maintained, and any new
hemoptysis during placement should be followed by pul-
monary angiogram. Keeping the catheter in place is debat-
able but may lead to faster identication of the injury, and
maintaining the balloon inated may decrease ow to the
ruptured segment thereby limiting hemorrhage.
 9 PULMONARY ARTERY CATHETERIZATION 125

Figure 95 Extravasation of contrast medium is visible on periph-

eral placement of the catheter during angiography. (Reprinted with
permission from Kierse R, Jensen U, Helmberger H, et al. Value of
multislice CT in the diagnosis of pulmonary artery pseudoaneurysm
from Swan-Ganz catheter placement. J Vasc Interv Radiol
2004;15:11331137.)

B
Figure 94 A, Multislice computed tomography (CT) shows
exact visualization of the aneurysm revealing perfused and throm-
bosed areas. B, The organ-optimized reconstruction with nearly
isometric resolution permits direct identication of the feeder
vessel and its connection to the aneurysm. (A and B, Reprinted
with permission from Kierse R, Jensen U, Helmberger H, et al.
Value of multislice CT in the diagnosis of pulmonary artery pseu-
doaneurysm from Swan-Ganz catheter placement. J Vasc Interv
Radiol 2004;15:11331137.)

Other important principles to remember when dealing

with this devastating complication include reversal of
anticoagulation, protecting the nonaffected lung from
aspirated blood by decubitus positioning (nonaffected
side up), placement of a double-lumen endotracheal tube,
and application of positive end-expiratory pressure. Figure
97 shows a treatment algorithm.
Figure 96 The aneurysm is sealed after placement of coils
in the feeder vessel. Note the stretched vessels associated with
the lesion. (Reprinted with permission from Kierse R, Jensen U,
Helmberger H, et al. Value of multislice CT in the diagnosis of
pulmonary artery pseudoaneurysm from Swan-Ganz catheter place-
ment. J Vasc Interv Radiol 2004;15:11331137.)
 126 SECTION II: BEDSIDE PROCEDURES

Suspected pulmonary artery perforation

Remove PA catheter

Minor hemoptysis Major airway Hemodynamic instability

(or herald hemorrhage) hemorrhage (without airway hemorrhage)

Defer elective surgery

Expectant treatment
A. Establish adequate gas exchange (ET and MV)

B. Isolation of lung---(DLET or BB)

C. Control of hemorrhage

Pre/post-op Intra-operative Pre/post-op

Hemodynamically (hemorrhage on Hemodynamically
stable weaning CPB) unstable

(Open bil.pleura/reinstitute CPB)

Emergent
(Appraisal of injury) thoracotomy
clamp hilum

Contained Extensive Injured central

parenchymal parenchymal and branch PA
hemorrhage hemorrhage or
pleural rupture

Pulmonary Arterial repair

reserve

Persistent
Poor Good
hypoxemia?

Temporary ECLS

Conservative therapy
Mechanical ventilation PA loop
and PEEP

Chest X ray and CT scan

Pulmonary angiogram

Bleeding PA perforation
PA pseudo aneurysm

Recurrent
Arterial embolization Pulmonary resection
hemorrhage?

Figure 97 Treatment algorithm. (Adapted from Sirivella S, Gielchinsky I, Parsonnet V, et al. Management of catheter-induced pulmonary
artery perforation: a rare complication. Ann Thorac Surg 2001;72:20562059.)
 9 PULMONARY ARTERY CATHETERIZATION
Prevention
Although Mullerworth and coworkers22 concluded that
catheter-induced pulmonary rupture is unavoidable,
education and training of those involved with insertion
is of utmost importance. Most ruptures occur with the
balloon inated and trying to obtain a PAOP, or wedge,
pressure. The ination time should be kept to a
minimum, and the person advancing the catheter
should watch the tracing. Upon insertion, once a PAOP
pattern is identied, the catheter must not be advanced
further. If a PAOP pattern is identied with partial
ination of the balloon or with the balloon deated,
the catheter should be moved back. The balloon ina-
tion syringe should be kept on the balloon port at all
times to avoid inadvertent uid injection into the
balloon. In addition, consider using the pulmonary
end-diastolic pressure to approximate PAOP, especially
in patients with pulmonary hypertension or other risk
factors for rupture.
Other Complications
Many rare complications have been reported. Most can be
avoided by remembering and practicing the principles for
safe insertion. Catheter emboli, usually caused by shearing
of the catheter just proximal to a knot, have been reported.
This can occur with any central vein catheter, and conser-
vative management carries a morbidity risk of 45% to 73%,
with mortality rates as high as 60%. Catheter emboli can
result in arrhythmias, thrombus, pulmonary emboli, sepsis,
and myocardial inammation or endocarditis.2327 Inter-
ventional radiologic techniques should be used to remove
these fragments, which often requires placing the frag-
ment in an accessible vein such as internal jugular or
femoral. Conservative management should be discour-
aged, unless comorbid conditions create an absolute con-
traindication to any invasive procedure (grade 3/4/5).
Damage of the tricuspid and pulmonary valves has been
reported, usually occurring by removing the catheter with
the balloon inated or coiling of the catheter around these
structures (grade 3/4/5).28
Most PA catheters are heparin-coated and may lead
to thrombocytopenia or even heparin-induced thrombo-
cytopenia. As always with this condition, a high index of
suspicion is required for timely diagnosis and intervention.
Nonheparin-coated PA catheters are available (grade
1/2).
Pulmonary infarction can occur and usually results from
placing the catheter too distal in the pulmonary arterial
system. It can also be a consequence of one of the afore-
mentioned complications, for example, catheter emboli or
postangiographic embolization.
Catheters have been reported to be placed in the coro-
nary sinus or persistent left-sided superior vena cava (grade
1).29,30 Migration through a patent ductus arteriosus and
into the aorta has been described in pediatric patients
(grade 1).31 Perforation of the right ventricle by a PA
127
catheter has been described, and in one such case, cardiac
output and mixed venous saturation measurements con-
tinued (grade 3/4).32
SUMMARY
PAC is associated with numerous complications. Main-
taining proper technique, careful examination of wave-
forms, and postprocedure x-rays should help minimize
complications and their morbidity.
REFERENCES
1. Swan HJC, Ganz W, Marcus H, et al. Catheterization of
the heart in men with use of a ow-directed balloon-
tipped catheter. N Engl J Med 1970;183:447451.
2. Connors AF Jr, Speroff T, Dawson NV, et al. The
effectiveness of right heart catheterization in the initial
care of critically ill patients. SUPPORT Investigators.
JAMA 1996;276:889897.
3. Gattinoni L, Pelosi P, Crotti S, Valenza F. Effects of
positive end-expiratory pressure on regional distribution of
tidal volume and recruitment in adult respiratory distress
syndrome. Am J Respir Crit Care Med 1995;151:1807
1814.
4. Bender JS, Smith-Meek MA, Jones CE. Routine pulmo-
nary artery catheterization does not reduce morbidity and
mortality of elective vascular surgery: results of a prospec-
tive randomized clinical trial. Ann Surg 1997;226:229
237.
5. Harvey S, Harrison D, Singer M, et al. An assessment of
the clinical effectiveness of pulmonary artery catheters in
patient management in intensive care (PAC-Man): a
randomized controlled trial. Lancet 2005;366:472
477.
6. Ivanov R, Allen J, Calvin J. The incidence of major
morbidity in critically ill patients managed with pulmonary
artery catheters: a meta-analysis. Crit Care Med 2000;28:
615619.
7. Wilson J, Woods I, Fawcett J, et al. Reducing the risk of
major elective surgery: randomized controlled trial of
preoperative optimisation of oxygen delivery. BMJ 1999;
318:10991103.
8. Truwit J. The pulmonary artery catheter in the ICU, part
1: technique and measurements. J Crit Illness 2003;18:9
19.
9. Mueller HS, Chatterjee K, Davis KB, et al. ACC Expert
Consensus Document. Present use of bedside right heart
catheterization in patients with cardiac disease. J Am Coll
Cardiol 1998;32:840864.
10. Pybus A. The St. George Guide to Pulmonary Artery
Catheterisation. Available at HONcode accreditation seal.
www.manbit.com/PAC/chapters/PAC.cfm (accessed May
7, 2008).
11. De Lange S, Boscoe MJ, Stanley TH. Percutaneous
pulmonary artery catheterization via the arm before
anaesthesia: success rate, frequency of complications and
arterial pressure and heart rate responses. Br J Anaesth
1981;53:11671172.
 128 SECTION II: BEDSIDE PROCEDURES
12. Sparks CJ, McSkimming I, George L. Shoulder manipula-
tion to facilitate central vein catheterization from the
external jugular vein. Anaesth Intensive Care 1991;19:
567568.
13. Tempe DK, Gandhi A, Datt V, et al. Length of insertion
for pulmonary artery catheters to locate different cardiac
chambers in patients undergoing cardiac surgery. Br J
Anaesth 2006;97:147149.
14. Ermakov S, Hoyt JW. Pulmonary artery catheterization.
Crit Care Clin 1992;8:773806.
15. Shah KB, Rao TL, Laughlin S, El-Etr AA. A review of
pulmonary artery catheterization in 6,245 patients.
Anesthesiology 1984;61:271275.
16. Sprung CL, Marcial EH, Garcia AA, et al. Prophylactic
use of lidocaine to prevent advanced ventricular arrhyth-
mias during pulmonary artery catheterization. Prospective
double-blind study. Am J Med 1983;75:906910.
17. Iberti TJ, Benjamn E, Gruppi L, Raskin JM. Ventricular
arrhythmias during pulmonary artery catheterization in the
intensive care unit. Am J Med 1985;78:451454.
18. Karanikas ID, Polychronidis A, Vrachatis A, et al. Removal
of knotted intravascular devices. Case report and review
of the literature. Eur J Endovasc Surg 2002;23:189
194.
19. Tan C, Bristol PJ, Segal P, Bell RJ. A technique to
remove knotted pulmonary artery catheters. Anaesth
Intensive Care 1997;25:160162.
20. Baqul NB, Menon NJ, Pathak R, et al. Knot in the cava
an unusual complication of Swan-Ganz catheters. Eur J
Vasc Endovasc Surg 2005;29:651653.
21. Abreau AR, Campos MA, Krieger BP. Pulmonary artery
rupture induced by a pulmonary artery catheter: a case
report and review of the literature. J Intensive Care Med
2004;19:291296.
22. Mullerworth MH, Angelopoulos P, Couyant MA, et al.
Recognition and management of catheter-induced
pulmonary artery rupture. Ann Thorac Surg 1998;66:
12421245.
23. Nellore A, Trerotola SO. Delayed migration of a catheter
fragment from the left to the right pulmonary artery. J
Vasc Interv Radiol 2004;15:497499.
24. Fisher RG, Ferreyro R. Evaluation of current techniques
for nonsurgical removal of intravascular iatrogenic foreign
bodies. AJR Am J Roentgenol 1978;130:541548.
25. Bernhardt LC, Mendenhall JT, Wegner GP. Intravenous
catheter embolization to the pulmonary artery. Chest
1970;57:329332.
26. Richardson JD, Grover FL, Trinkle JK. Intravenous
catheter emboli. Experience with twenty cases and
collective review. Am J Surg 1974;128:722727.
27. Wellmann KF, Reinhard A, Salazar EP. Polyethylene
catheter embolism. Review of the literature and report of
a case with associated fatal tricuspid and systemic candidia-
sis. Circulation 1968;37:380392.
28. OToole JD, Wurtzbacher JJ, Weaner NE, Jain AC.
Pulmonary-valve injury and insufciency during pulmo-
nary-artery catheterization. N Engl J Med 1979;22:301:
11671168.
29. Baciewicz FA, Nirdlinger MA, Davis JT. An unusual
position of a Swan Ganz catheter. Intensive Care Med
1987;13:211212.
30. Lai YC, Goh JCY, Lim SH, Seah TG. Difcult pulmonary
artery catheterization in a patient with persistent left
superior vena cava. Anaesth Intensive Care 1998;26:
671673.
31. Moore RA, McNicholas K, Gallagher JD, Niguidula F.
Migration of pediatric pulmonary artery catheters.
Anesthesiology 1983;58:102104.
32. Chuang KC, Lan AKM, Luk HN, et al. Perforation of
the right ventricle by a pulmonary artery catheter that
continues to measure cardiac output and mixed venous
saturation. J Clin Anesth 2005;17:124127.
10
Arterial Catheterization
Elizabeth A. David, MD and
Stephen R. T. Evans, MD
INTRODUCTION
Continuous arterial pressure monitoring and direct arte-
rial blood samplings are the two most common indica-
tions for arterial catheterization, which is typically used for
perioperative monitoring during major surgical proce-
dures and in critically ill patients. Common sites of
cannulation include radial, femoral, and axillary arteries,
and the most frequently reported complications include
vascular insufciency, bleeding, and infection. Despite
reported complications, numerous studies have demon-
strated the safety of arterial cannulas for monitoring in
both the surgical and the medical intensive care settings.1
In an extensive review of the literature from 1978 to
2001, Scheer and coworkers1 reported a major complica-
tion rate of less than 1% in over 25,505 attempts at can-
nulation of the radial, femoral, and axillary arteries.
INDICATIONS
Continuous arterial pressure monitoring
Direct arterial blood sampling
OPERATIVE PROCEDURE
Radial Artery Cannulation
Scheer and coworkers1 found temporary occlusion of the
radial artery to be the most common complication, with
an incidence rate from 1.5% to 35%. Complications after
radial cannulation have also been reported: hematoma
formation (14% incidence rate), local infection (0.7%),
bleeding (0.5%), pseudoaneurysm (0.09%), and perma-
nent ischemic damage (0.09%).1
Thrombosis
Consequence
Occlusive complications plague all of the common sites
for arterial cannulation. Arterial spasm and pulseness
are more commonly seen after new-site insertion,
whereas vascular insufciency and bleeding were more
common after line changes over a guidewire.2
Grade 1/2 complication
Repair
Catheter removal is typically sufcient therapy except
in extreme circumstances, as noted under Pseudoan-
eursym, later in this chapter.
Prevention
Thrombotic complications can be avoided and mini-
mized through the use of smaller-gauge catheters (20-
gauge) and Teon catheters.3 Minimizing the number
of punctures has also been shown to be an effective
means of minimizing the chance of thrombotic com-
plications.4 Slogoff and associates4 also demonstrated
an increased risk of occlusive complications in patients
who also have hematoma, which is also related to mul-
tiple puncture attempts. Beards and colleagues5 in a
randomized, controlled trial demonstrated that arterial
cannula insertion using a Seldinger technique resulted
in fewer puncture attempts and fewer occlusive prob-
lems than a direct puncture method of cannula inser-
tion. Similarly, Mangar and coworkers6 demonstrated
an 82% success rate when cannulating the radial artery
using a guidewire versus only 65% success when a direct
puncture method was used. The use of heparinized
ush solution made no difference in the maintenance
of cannula patency versus ushing with normal saline;
however, more accurate blood pressure monitoring was
recorded in patients receiving heparinized ush solu-
tions than in those with cannulas ushed with normal
saline only.7 Low-dose aspirin or low-dose heparin
therapy pretreatment has been demonstrated to mini-
mize the risk of occlusive complications after arterial
cannulation.8
Infection
Consequence
Whether or not cannula site inuences infection rate
after arterial cannulation is controversial. Frezza and
associates2 found that the infection rate of 0.4% to 0.7%
does not vary regardless of line site and that serial
 130 SECTION II: BEDSIDE PROCEDURES
changing of the arterial cannulation site made no
difference in terms of the complications reported.
However, in a large prospective observational study,
Lorente and coworkers9 demonstrated a higher risk of
catheter-related line infections and catheter-related
bloodstream infections with femoral arterial cannulas
than with radial cannulas.9
Grade 1 complication
Repair
Appropriate antibiotic therapy and catheter removal
will typically provide sufcient therapy.
Prevention
Sterile insertion technique, adequate disinfection of
cannulation site, and length of cannulation have been
demonstrated to be crucial factors for decreasing the
incidence of cannula-related infections.10 Mimoz and
colleagues10 compared the use of chlorhexidine with
iodine preparation solutions for both sterilization of
the insertion site and maintenance of indwelling cannula
sites in a prospective, randomized trial and found that
the chlorhexidine solution was more effacious at pre-
vention of infection at cannula sites. This effect was
attributed to chlorhexidines effect on gram-positive
organisms.10
Pseudoaneurysm (Fig. 101)
Pseudoaneurysm after radial cannulation has a mean inci-
dence of 0.09% in the literature and is typically managed
Proper palmar
digital arteries
Common palmar
digital arteries
Palmar metacarpal
arteries
Princeps pollicis artery
Deep palmar
arterial arch Superfical palmar branch
of radial artery
Ulnar artery Radial artery
with ligation of the radial artery after an Allen test dem-
onstrates collateral ow.11
Consequence
Perez and associates12 reported a case of pseudoaneu-
rysm requiring ligation of the radial artery and eventu-
ally resulting in septic shock.
Grade 13 complication
Repair
Ligation of the radial artery may be required if an Allen
test demonstrates sufcient ulnar arterial collateral
ow.12
Prevention
Pseudoaneurysm is typically seen later after catheteriza-
tion (740 days). Factors that were associated with
pseudoaneurysm included repeated puncture attempts,
alterations of vessel walls, and catheter infections.12
Ganchi and coworkers13 demonstrated that the pres-
ence of Staphylococcus aureus infection and signs of
infection lasting longer than 48 hours after cannula
removal or initiation of antibiotics are directly corre-
lated with the development of pseudoaneurysm.13
Therefore, early recognition of signs of infection
and minimizing the time of catheterization may help
reduce the incidence of pseudoaneurysm after radial
cannulation.
Proper digital arteries
of thumb
Radial indicis artery
Figure 101 The radial and ulnar arteries provide
collateral ow to the hand, which allows for ligation
in the presence of a pseudoaneurysm.

Hand Ischemia
Hand ischemia is a rare, but reported complication of
radial arterial cannulation.
Consequence
Valentine and associates14 reported a series of eight
patients (incidence estimated to be 1 in 1000) who
experienced hand ischemia after radial arterial throm-
bosis following arterial cannulation. Patient outcomes
included hospital death, nger gangrene requiring
amputation, chronic pain, and cold intolerance; one
patient was asymptomatic.14
Grade 15 complication
Repair
Patients were treated with a combination of thrombec-
tomy, patch angioplasty, vein graft interposition, and
medical therapies.14
Prevention
Risk factors for hand ischemia included coronary artery
disease, diabetes mellitus, end-stage renal disease,
heparin-induced thrombocytopenia, and peripheral
arterial occlusive disease. Duration of cannulation
varied from 1 to 14 days prior to presentation with
ischemic symptoms. All patients were noted to have
compromised ulnar arterial ow at the time of vascular
surgery evaluation. Embolization from radial arterial
thrombus leading to occlusion of distal arteries sup-
plied by the palmar arch may be responsible for hand
ischemia and provide explanation for the persistence of
digital ischemia despite thrombectomy and reperfusion
therapies.14 Recognizing risk factors, minimizing dura-
tion of cannulation, and maintaining ulnar arterial ow
are keys to preventing hand ischemia.
Femoral Artery Cannulation
The femoral artery is the second most common site can-
nulated for invasive blood pressure monitoring and fre-
quent blood sampling. Unlike complications with the
radial artery, hematoma and bleeding were the most fre-
quently reported complications (mean incidence of 6.1%
and 1.58%, respectively) followed by temporary occlusion
(mean incidence of 1.45%).1 The literature contains reports
of pseudoaneursym, local infection, and even death after
retroperitoneal bleeding.
Retroperitoneal Bleeding (Fig. 102)
Consequence
Death after retroperitoneal bleeding after placement
of a right femoral arterial catheter was reported by
Muralidhar15 in a 22-year-old patient who had under-
gone correction of tetralogy of Fallot requiring cardio-
pulmonary bypass. The patients death was attributed
to multiple attempts at cannulation that led to bleeding
10 ARTERIAL CATHETERIZATION 131
further exacerbated by the systemic heparinization
required for bypass.15
Grade 15 complication
Repair
Primary repair and mechanical tamponade via pressure
or packing are the most readily available options for
repair.
Prevention
Muralidhar15 suggested puncture of the femoral artery
below the inguinal ligament, adequate compression of
the puncture site after failed attempts, using a small-
gauge catheter, and avoiding cannulation by inexperi-
enced personnel as means of avoiding this morbidity
associated with femoral cannulation.15
Axillary Artery Cannulation
The axillary artery is the third most common site for arte-
rial cannulation, and although it requires cutdown for
access to be safely attained, some studies suggest a lower
complication rate than with alternate sites of cannulation.
The most common complications reported by Scheer
and coworkers1 were hematoma and local infection (mean
incidence of 2.28% and 2.24%, respectively).
Local Infection
Consequence
The rates of local infection are the highest for axillary
cannulation of the three common sites. Some studies
have attributed an increased incidence of sepsis in the
presence of local infection to care and monitoring of
the actual system.16
Grade 1 complication
Repair
Antibiotics are typically necessary only in cases of
sepsis. Local infection will clear when the catheter is
removed.
Prevention
Maki and Hassemar16 suggested that the pressure mon-
itoring apparatus should be changed every 48 hours to
minimize the risk of infection and sepsis in patients
with in-dwelling cannulas.
Hand Paresthesia (Fig. 103)
Consequence
A unique complication for axillary cannulation is
paresthesia of the hand secondary to pressure on the
brachial plexus, which has been described by Brown
and colleagues,17 who concluded that despite this com-
plication and others described earlier, the axillary artery
is wa safe alternative site when the radial artery is
unavailable.
Grade 1/2 complication
132 SECTION II: BEDSIDE PROCEDURES

Figure 102 A, The femoral artery above and below the inguinal
canal. C, Below the inguinal canal, the femoral artery can be compressed
using direct pressure against the femoral head. B, Above the inguinal
A ligament, pressure cannot be applied which can increase the risk of
retroperitoneal bleeding.
 10 ARTERIAL CATHETERIZATION 133

Lateral cord
Medial cord
Axillary artery

Musculocutaneous
nerve

Median nerve
Ulnar nerve
Brachial artery

Medial cutaneous
nerve of forearm C5
C6
C7
C8
T1
Inferior trunk
Middle trunk
Superior trunk

Lateral cord
Radial artery Posterior cord
B Medial cord

Median nerve
Ulnar nerve
A Ulnar artery

Musculocutaneous nerve

Median nerve

Axillary artery

Ulnar nerve

Brachial artery
Biceps muscle

Median nerve

Ulnar nerve

Figure 103 A and B, The axilla demonstrates the relationship

between the axillary artery and the brachial plexus. C, When the
brachial plexus is compressed during arterial cannulation, hand
ischemia can result. C
 134 SECTION II: BEDSIDE PROCEDURES
Repair
Catheter removal will generally restore normal sensa-
tion to the hand.
Prevention
Positioning of the catheter and short duration of cath-
eterization may minimize this complication.
SUMMARY
In summary, arterial cannulation is a safe and effective
means of perioperative monitoring and frequent blood
sampling in critically ill patients. The radial artery is the
preferred site of cannulation, but when it is unavailable,
the femoral and axillary arteries have been demonstrated
to be safe. The common complications of thrombosis and
infection can be minimized by using small-gauge cathe-
ters, chlorhexidine preparation solutions, Seldinger tech-
nique for insertion, and early removal of cannulas to
minimize the duration of catheterization.
REFERENCES
1. Scheer BV, Perel A, Pfeiffer UJ. Clinical Review: Compli-
cations and risk factors of peripheral arterial catheters used
for hemodynamic monitoring in anesthesia and intensive
care medicine. Crit Care 2002;6:198204.
2. Frezza EE, Mezghebe H. Indications and complications
of arterial catheter use in surgical or medical intensive care
units: analysis of 4932 patients. Am Surg 1998;64:127
131.
3. Davis FM. Radial artery cannulation: inuence of catheter
size and material on arterial occlusion. Anesth Intensive
Care 1978;6:4953.
4. Slogoff S, Keats AS, Arlund C. On the safety of radial
artery cannulation. Anesthesiology 1983;59:4247.
5. Beards SC, Doedens L, Jackson A, Lipman J. A compari-
son of arterial lines and insertion techniques in critically ill
patients. Anaesthesia 1995;50:576.
6. Mangar D, Thrush DN, Connell GR, Downs JB. Direct
or modied Seldinger guide wiredirected technique for
arterial catheter insertion. Anesth Analg 1993;76(4):714
717.
7. Kulkarni M, Elsner C, Ouellet D, Zeldin R. Heparinized
saline versus normal saline in maintaining patency of the
radial artery catheter. Can J Surg 1994;37:3742.
8. Bedford RF, Ashford TP: Aspirin pretreatment prevents
post-cannulation radial-artery thrombosis. Anesthesiology
1979;51:176178.
9. Lorente L, Santacreu R, Martin MM, et al. Arterial
catheterrelated infection of 2,949 catheters. Crit Care
2006;10:R83
10. Mimoz O, Pierone L, Lawrence C, et al. Prospective,
randomized trial of two antiseptic solutions for prevention
of central venous or arterial catheter colonization and
infection in intensive care unit patients. Crit Care Med
1996;24:18181823.
11. Stansby G, Smout J, Chalmers R, Lintott R. MRSA-
infected pseudoaneurysms of the radial artery. Surgeon
2003;1:108110.
12. Perez L, Jiminez G, Ruiz J. Pseudoaneurysm in the radial
artery after catheterization. Rev Esp Anestesiol Reanim
2006;53:119121.
13. Ganchi PA, Wilhelmi BJ, Fujita K, Lee WP. Ruptured
pseudoaneurysm complicating an infected radial artery
catheter: case report and review of the literature. Ann
Plast Surg 2001;46:647650.
14. Valentine RJ, Modrall JG, Clagett GP. Hand ischemia
after radial artery cannulation. J Am Coll Surg 2005;201:
1822.
15. Muralidhar K. Complication of femoral artery pressure
monitoring. J Cardiothorac Vasc Anesth 1998;12:128
129.
16. Maki DG, Hassemar C. Endemic rate of uid contamina-
tion and related septicemia in arterial pressure monitoring.
Am J Med 1981;70:733738.
17. Brown M, Gordon LH, Brown OW, Brown EM. Intravas-
cular monitoring via the axillary artery. Anaesth Intensive
Care 1985;13:3840.
11
Chest Tube Insertion
Aarti Mathur, MD and Stephen R. T. Evans, MD
INTRODUCTION
Drainage of the pleural space by means of tube thoracos-
tomy is a common procedure performed for a variety of
well-established indications. Although chest tube inser-
tion is considered a simple procedure by experienced phy-
sicians, morbidity rates as high as 36% have been reported.1,2
Factors associated with a higher complication rate include
technique of insertion, emergent placement of chest tube,
operator performing the procedure, and the length of
time that the tube is in place.2,3 In addition, increased
severity of injury correlates with a higher complication
rate, although the mechanism of chest injury, blunt versus
penetrating, does not.2
INDICATIONS 1,4
A chest tube essentially functions to remove air, uid, or
pus from the intrathoracic space.
Pneumothorax
Tension pneumothorax
Hemothorax
Penetrating chest injury
Drainage of malignant pleural effusion
Parapneumonic effusions: simple or complicated with
empyema
Pleurodesis for intractable symptomatic effusions
Chylothorax
Bronchopleural stula
OPERATIVE STEPS
Step 1 Position the patient
Step 2 Choose the drain insertion sitenipple level
(fth intercostal space) just anterior to the
midaxillary line
Step 3 Prepare and drape the chest using sterile tech-
nique at the chosen site of insertions
Step 4 Anesthetize the skin and periosteum
Step 5 Skin incision and blunt dissection through sub-
cutaneous tissue down to the rib
Step 6 Puncture the parietal pleura just above the rib
Step 7 Place a gloved nger into the incision and sweep
360
Step 8 Advance a proximally clamped thoracostomy
tube and direct it in the desired direction
Step 9 Connect the end of the thoracostomy tube to
an underwater-seal apparatus
Step 10 Suture the tube in place and apply a dressing
Step 11 Obtain a chest x-ray
OPERATIVE PROCEDURE
Patient Positioning
The ideal position for chest tube insertion is supine on a
bed, slightly rotated, with the arm on the side of the lesion
behind the patients head to expose the axillary area. This
positioning exposes the safe triangle and reduces the
risk of injuring underlying muscle and breast tissue.5
Choose Drain Insertion Site
Diaphragmatic Perforation
Consequence
Placement of a chest tube outside of the thoracic cavity
or a diaphragmatic injury will result in an iatrogenic
pneumothorax, an unresolved pneumothorax, or a
tension pneumothorax.6,7 Placement of the chest tube
through or below the diaphragm will cause the tube
to become lodged in the abdominal cavity, and the
pulmonary pathology initially requiring the tube
will persist. The consequences, repair, and prevention
of intra-abdominal placement of a tube are discussed
later.
Grade 1/2 complication
Repair
A second chest tube must be placed into the pleural
space and the initial tube removed. The diaphragm
does not need to be repaired as long as a functional
chest tube is present on that side.
Prevention
Insertion should be in the safe triangle bordered by
the anterior border of the latissimus dorsi, the lateral
 136 SECTION II: BEDSIDE PROCEDURES
Cupula (dome)
of pleura
Diaphragm
border of the pectoralis major muscle, a line superior
to the horizontal level of the nipple, and an apex below
the axilla.5 During full expiration, the diaphragm rises
to the fth rib/fourth intercostal space (Fig. 111).
Identifying a site in the fourth intercostal space midax-
illary line helps to avoid diaphragmatic and abdominal
cavity penetration. The highest rib space in the axilla
adjacent to the nipple is usually the fourth or fth, or
alternatively, the rib spaces may be counted down from
the second rib at the sternomanubrial joint (Fig. 112;
see also Fig. 111).8
Aseptic Technique/Surgical Preparation
and Draping
Wound Site Infection
Consequence
Infection of the wound site results in cellulitis, leuko-
cytosis, and an increased risk of developing an empyema
or necrotizing soft tissue infection. Necrotizing soft
tissue infection typically presents with wound pain;
crepitus; foul, watery wound discharge; skin blistering;
and rapid progression to septic shock 3 to 5 days after
insertion of a chest tube.9 A chest tube placed for an
empyema is associated with an increased risk of devel-
oping a necrotizing chest wall infection.
Grade 2/3 complication
Repair
A simple wound site infection typically consists of
Staphylococcus aureus and responds to antibiotics.
Necrotizing soft tissue infections are highly lethal
and require aggressive surgical dbridement and high-
Apex of lung
Spleen
Liver
Stomach
Pancreas
Figure 111 During full expiration, the
diaphragm rises to the fth rib/fourth inter-
costal space. Therefore, identifying a site
in the fourth intercostal space helps to
avoid diaphragmatic and abdominal cavity
penetration.
dose antibiotics. Reconstructive surgery may eventually
be required.
Prevention
A large area of skin cleansing using iodine or chlorhex-
idine should be undertaken.5 Prophylactic antibiotics
do not reduce the incidence of wound infections in
routine chest tube placement and are, therefore, not
indicated.10,11 However, they may be considered in the
setting of penetrating trauma. The wound site should
be examined daily.
Thoracic Empyema
Consequence
An empyema may cause respiratory compromise/
failure. The incidence of this complication reported
in the literature varies widely from 1% to 25%.12 The
true source and route of infection may be difcult to
determine; however, the rate of empyema is higher
when a pleural effusion is present prior to tube
insertion.12
Grade 2/3 complication
Repair
An empyema can be drained via closed tube thoracos-
tomy and treated with intravenous antibiotics. However,
if it continues to persist, a thoracotomy and decortica-
tion will be required.
Prevention
Although tube thoracostomy may lead to infectious
complications by providing an entrance for contamina-

Figure 112 During inspi-
ration, the diaphragm lies A
several rib spaces lower.
tion, the true route and source of infection for develop-
ment of an empyema are difcult to determine.12 The
best way to prevent empyema is by use of the aseptic
technique. Prophylactic antibiotics have not been
shown to reduce the incidence and, therefore, are
not recommended for routine use of chest tube
placement.10,11,13
Anesthesia/Analgesia14
Lack of Appropriate Analgesia
Consequence
Lack of appropriate analgesia creates a mobile patient,
which increases the difculty of the procedure. This
11 CHEST TUBE INSERTION 137
increases the likelihood of most of the complications
discussed in this chapter.
Grade 1 complication
Repair
If the patient is experiencing pain causing her or him
to move, the procedure should be placed on hold until
adequate analgesia or sedation is administered.
Prevention
Providing the patient with adequate analgesia aids in
ease of performing the procedure. It has been recom-
mended to use about 10 to 20 ml of lidocaine to rst
create a dermal bleb and then to direct the needle
perpendicular to the skin to inltrate the muscles of the
 138 SECTION II: BEDSIDE PROCEDURES

chest wall. This includes the intercostal muscles, down

to the rib, injecting around the periosteum of the rib.
The needle is then angled above the rib until air is
aspirated. The remaining 5 ml can be injected into the
pleural space.

Incision and Blunt Dissection

Damage to Intercostal Artery or Vein
Consequence
Damage to an intercostal vessel may cause an iatrogenic Intercostal v.
hemothorax. In rare instances, it may result in an arte-
Intercostal a.
riovenous stula either between an intercostal artery
and a subcutaneous vein or from an internal thoracic Intercostal n.
artery draining into a lobar pulmonary artery.15 The
clinical manifestations of a stula may be immediate or
delayed.
Grade 2/3 complication
Kelly clamp
Repair parallel to body
The hemothorax is best treated by adequate pleural
drainage with the chest tube; however, if it is massive,
a thoracotomy may be required. Treatment of arterio-
venous stulas is based on clinical symptoms, and
options range from surgical removal of the stula to
transcatheter embolization.15

Prevention
A transverse incision is made parallel to and along the
upper border of the rib below the intercostal space to
be used. The size of the incision should be slightly
larger than the operators nger and the tube. Blunt
dissection using a Kelly clamp is carried out until the
surface of the rib is encountered. A drain track is then
created cranially using a Kelly clamp and blunt nger
dissection so that it is directed over the top of the rib.
This avoids the intercostal vessels lying below each rib.1
Excessive bleeding during insertion of a chest tube
should raise the possibility of development of a
stula.15
Damage to the Intercostal Nerve16
Consequence
Neuritis/neuralgia from intercostal nerve damage can
present with pain, numbness, tingling, and muscle
atrophy.
Grade 1 complication
Repair
The mainstay in treatment is analgesia, physiotherapy,
and occasionally, topical capsaicin.
Prevention
The intercostal nerve runs with the artery and vein
below each rib. Thus, in attempting to prevent injury
to the vessels, the nerve will be preserved as well
(Fig. 113).
Figure 113 The Kelly clamp should be directed immediately
above the rib to avoid injury to the intercostal neurovascular
bundle.
Fingersweep
Lung Laceration
Consequence
A lung laceration may manifest in several different ways
including bleeding; development of a new, iatrogenic,
or unresolving persistent pneumothorax; and in severe
cases, a bronchopleural stula (BPF) or bronchocuta-
neous stula.17,18 A BPF typically presents with sudden-
onset dyspnea, hypotension, subcutaneous emphysema,
and cough with expectoration of purulent uid.
Although rare, BPF presents a challenging manage-
ment problem and is associated with high morbidity
and mortality.17 A bronchocutaneous stula slowly
develops after a chest tube has been in place for a
longer period of time and is diagnosed with radiogra-
phy after that tube is removed.
Grade 3/4 complication

Lung
Adhesions from
lung to chest wall
Gloved hand
is left of nipple
Diaphragm
Figure 114 A ngersweep is performed by rotat-
ing a nger 360 degrees inside the pleural cavity to
break down any pleural adhesions to avoid lung lac-
eration, pneumothorax, bronchocutaneous stula,
and bleeding.
Repair
Pneumothorax, bronchocutaneous stula, and bleed-
ing will require tube thoracostomy drainage. A thora-
cotomy is indicated for massive hemothorax. Initial
management of a patient with a BPF includes contin-
ued chest drainage and positioning of the patient on
his or her side, with the side of the BPF being down.
Long-term management involves various procedures
including bronchoscopy with different glues, coils, and
sealants.17
Prevention
The thoracic cavity is entered using the clamp imme-
diately above the rib. Excessive force is not necessary
and may cause a lung laceration. Once the cavity is
punctured, the clamps should be spread open widely
to allow insertion of a nger and the tube. A nger is
then inserted and rotated around 360. This allows
breakdown of any pleural adhesions that may position
the lung against the chest wall and make it prone to
injury (Fig. 114).8
Intra-Abdominal Placement
Consequence
Intra-abdominal placement of a chest tube has a
wide variety of sequelae ranging from laceration of
the spleen or liver, resulting in bleeding, to avulsion
injury or perforation of stomach or colon, resulting in
11 CHEST TUBE INSERTION 139
peritonitis.7 In addition, the primary pulmonary pathol-
ogy requiring the tube remains untreated.8
Grade 3/4 complication
Repair
Intra-abdominal placement can be conrmed by a plain
lm. Another chest tube must be placed in the chest,
the intra-abdominal tube should be removed, and the
patient should be closely monitored. In the case of a
liver or splenic laceration, serial hematocrits and follow-
up imaging should be obtained to ensure cessation of
bleeding. Peritonitis may result from perforated viscus.
Hemodynamic instability and peritonitis necessitate
operative intervention.
Prevention
Initial choice of an appropriate drain site is critical to
prevent intra-abdominal placement, as described earlier.
The ngersweep conrms placement into the thoracic
cavity. The rst solid organ felt after a gloved nger is
inserted should be the lung. The surface of the dia-
phragm may also be felt when the nger is rotated
inferiorly to ensure placement into the thoracic cavity
and evaluate for a diaphragmatic laceration.1,6 Although
placement into the chest may be conrmed, injury to
intra-abdominal organs may also result from emergent
chest tube placement in a patient with an unrecognized
diaphragmatic hernia (Fig. 115).6
 140 SECTION II: BEDSIDE PROCEDURES
Finger sweep
below diaphragm
Figure 115 A ngersweep will aid in detection of intra-
abdominal penetration and avoid incorrect placement of a chest
tube.
Placement of Tube and Position of Tube Tip
Placement into Subcutaneous Tissue8
Consequence
Placement of a chest tube outside the thoracic cavity
in the subcutaneous tissues will result in an unresolved
pnemothorax or effusion. In addition, it may cause a
tension pneumothorax because air has been allowed to
enter the thoracic cavity from the initial puncture site.
These complications may also be noted in a chest tube
that has been placed inside the correct cavity when all
of the holes of the tube are not inside the cavity.
Repair
Subcutaneous chest tube placement can be conrmed
by chest x-ray and/or worsening clinical symptoms. An
intra-thoracic chest tube must be immediately placed.
After conrmation of correct placement of the second
chest tube, the rst tube may be removed.
Prevention
The actual placement of the tube into the puncture site
created by the Kelly clamp can often be difcult and
challenging. However, an appropriate-sized track and
a large enough opening into the thoracic cavity will
make this step of the procedure easier and reduce the
risk of subcutaneous tissue placement. The blunt dis-
section should be minimal, creating a single track until
the pleural cavity is punctured. A track that is too wide
or has gone more superior than the puncture site may
make it easier to miss the opening into the thoracic
cavity. This can also occur if the entrance to the cavity
is not wide enough. Once the thoracic cavity is punc-
tured, the Kelly clamp should be widely opened to
provide a large enough space to accommodate the
chest tube and a clamp. Before the tube is inserted, it
should be mounted on a clamp and passed along the
track into the pleural cavity until the last hole of the
drain is inside of the cavity. The tube should slide in
easily; if excessive force is required, the tube should be
taken out and another attempt made to slide it in the
pleural cavity opening.
Placement Too Far into Apex or Mediastinum
Consequence
A variety of complications have been reported from
chest tubes that have been placed too far into the lung
apex or that abut the mediastinum. The tube may abut
major vascular structures such as the subclavian artery
and cause an obstruction or even disruption.19,20 Direct
injury to the artery is unlikely at the time of insertion;
however, it may occur secondary to vessel erosion from
direct contact with the tube over a period of time.
Rarer complications include brachial plexus compres-
sion causing pain, sudden death from vagus nerve irri-
tation, extubation failure secondary to phrenic nerve
injury, partial aortic obstruction, contralateral pneumo-
thorax, and esophageal perforation.19,21
Grade 3/4 complication
Repair
A chest radiograph should be obtained immediately
after insertion, and any tube that is found to be in a
dangerous position, too far into the apex, or abutting
the mediastinum should be repositioned immediately.
If profuse bleeding is noted from a chest tube, thora-
cotomy is indicated to determine the source and control
the bleeding. Cessation of bleeding may be managed
with careful repositioning of the chest tube and sub-
sequent radiographic conrmation.
Prevention
The tip of any intrathoracic tube should not rest in
either the apex of the thorax or the mediastinum. The
nal resting place of the tube is determined in part by
the direction of the track it follows through the chest
wall. If a drain is to lie anteriorly in the chest, the track
should be developed in a slightly anterior direction.
Typically, a chest tube is placed apically for a pneumo-
thorax and basally for drainage of an effusion.5 Place-
ment should not require excessive force. Because most
chest tubes placed too far into the apex cause symptoms
related to the duration of placement of the tube, the
best way to prevent these complications is to check a
chest lm immediately after the tube has been placed
and to reposition any suspicious tube.
Placement Abutting Mediastinum
Consequence
If a chest tube is placed with excessive force, perfora-
tion of the left ventricle or right atrium may occur,
resulting in cardiac tamponade.22,23 Cardiogenic shock

and various arrhythmias, especially rapid atrial brilla-
tion, may result if a tube abuts and irritates the medi-
astinum.24 Rarely, in patients who have had a previous
coronary bypass, vein compression can produce myo-
cardial ischemia.19 Rarely, the phrenic nerve may be
injured where it runs over the mediastinum.19,25 Patients
with cardiomegaly are at increased risk for these
complications.
Grade 3/4/5 complication
Repair
If the chest radiograph obtained after insertion of the
chest tube shows the tube to abut the cardiac silhou-
ette, the tube should be repositioned and placement
conrmed with x-ray. If cardiac tamponade or perfora-
tion is suspected, an echocardiogram may conrm
the diagnosis. However, operative intervention is
necessary.
Prevention
Simple pneumothorax causes mediastinal shift toward
the affected side, making the pericardium prone to
laceration. Therefore, no excessive force should be used
to place a chest tube. Placement of a chest tube ideally
should be performed under electrocardiographic mon-
itoring to assess for mediastinal irritation. If electrocar-
diographic changes are present during the procedure
or if resistance is met while inserting the tube, it should
be repositioned. In addition, a chest radiograph should
be checked immediately after placement; if the tube
appears to be abutting the mediastinum, it should be
repositioned.
Drain Becomes Nonfunctional (Kink/Clot)7,19
Consequence
A nonfunctional drain will result in an undrained effu-
sion, hemothorax, unresolved pneumothorax, or in
extreme instances, a tension pneumothorax. A tube
typically becomes nonfunctional once it is lled with
clot, debris, or lung tissue, which can result in infarc-
tion of lung tissue.
Grade 3/4 complication
Repair
Once a nonfunctional drain is identied, a second drain
needs to be placed and, after radiographic conrmation
of successful placement, the rst drain should be
removed.
Prevention
Key to preventing clotting of a chest tube is to choose
the appropriate drain size. Smaller drains tend to kink/
clot easier than larger drains, especially when used in
the setting of trauma because of the high incidence of
hemothorax.26 The major determinant to size selection
is the ow rate of either the air or the liquid that can
11 CHEST TUBE INSERTION 141
accommodated by the tube. The internal diameter
(bore) of the tube and, less so, the tube length are the
critical ow determinants. Twenty percent of patients
with chest trauma have accompanying hemothorax and
pneumothorax. Therefore, given the potential need for
evacuation of both air and blood, a large-bore (28
36 Fr) chest tube is recommended. In hemodynami-
cally stable, nonmechanically vented patients with
primary or secondary spontaneous pneumothorax, a
small-bore chest tube (16 or 22 Fr) may be placed. A
mechanically vented patient with an iatrogenic pneu-
mothorax or a patient who needs uid drained should
have a tube greater than 28 Fr placed.13,2729
The inadvertent occlusion of drains by normal patient
positioning can be potentially life-threatening. Because
the tubing is soft and elastic, it is predisposed to frequent
bending and kinking, which if done at right angles, has
the effect of clamping outow. This can be minimized by
frequent monitoring of the tube and appropriate taping.
It has been suggested that tting a standard corrugated
ventilator circuit over the drain can provide an outer
support layer to stiffen the tubing.30
The drain may also be blocked with lung tissue. If a
track is directed posteriorly, the drain can fall back to lie
in the oblique ssure where it may become blocked. Chest
radiographs must be checked, and this blockage can be
suspected in a patient who is clinically deteriorating with
no chest tube output.
Secure Drain
Pneumothorax or Effusion
Consequence
A pneumothorax or effusion may persist if the tube
starts to come out of or fall out of the thoracic cavity,
and in severe cases, a tension pneumothorax may
result.19 Subcutaneous emphysema may be noted
around the skin site.
Grade 1/2 complication
Repair
A second chest tube needs to be placed for a nonfunc-
tional chest drain in the setting of a persistent effusion,
pneumothorax, or tension pneumothorax.
Prevention
Once a chest tube is placed, ensuring that the last hole
of the drain is inside of the thoracic cavity, it should be
appropriately sutured and a sterile dressing placed.
Complications of Chest Tube Insertion
Reexpansion Pulmonary Edema3133
This refers to a unilateral pulmonary edema that can rarely
occur on either the ipsilateral or the contralateral side after
evacuation of a pleural effusion or pneumothorax. This is
 142 SECTION II: BEDSIDE PROCEDURES
a rare but serious complication that carries a mortality rate
as high as 20%. Although the pathophysiology remains
obscure, both mechanical and inammatory processes are
believed to contribute to its development. The risk of
developing reexpansion pulmonary edema is associated
with duration and severity of lung collapse and the rate of
reexpansion.
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1. Millikan JS, Moore EE, Steiner E. Complications of tube
thoracostomy for acute trauma. Am J Surg
1980;140:738741.
2. Etoch SW, Bar-Natan MF, Miller FB, Richardson JD.
Tube thoracostomy. Factors relating to complications.
Arch Surg 1995;130:521525.
3. Resnick DK. Delayed pulmonary perforation: a rare
complication of tube thoracostomy. Chest 1993;103:311
313.
4. Miller KS, Sahn SA. Chest tubes: indications, technique,
management and complications. Chest 1987;91:258264.
5. Laws D, Neville E, Duffy J. BTS guidelines for the
insertion of a chest drain. Thorax 2003;58(suppl II):ii53
ii59.
6. Hyde J. Reducing morbidity from chest drains. BMJ
1997;314:914915.
7. Bailey RC. Complications of tube thoracostomy in
trauma. Emerg Med J 2000;17:111114.
8. Advanced Trauma Life Support Team Manual. Chest
trauma management. In American College of Surgeons
Advanced Trauma Life Support for Doctors, 7th ed.
Chicago: First Impression, 2004; p 125.
9. Urschel JD, Takita H, Antkowiak JG. Necrotizing soft
tissue infections of the chest wall. Ann Thorac Surg 1997;
64:276279.
10. Luchette FA, Barrie PS, Oswanksi MF, et al. Practice
management guidelines for prophylactic antibiotic use in
tube thoracostomy for traumatic hemothorax: the EAST
Practice Management Guidelines Work Group. J Trauma
2000;48:753757.
11. Wilson RF, Nichols RL. The EAST practice management
guidelines for prophylactic antibiotic use in tube thoracos-
tomy for traumatic hemothorax: a commentary. J Trauma
2000;48:758759.
12. Chan L, Reilly KM, Henderson C. Complication rates of
tube thoracostomy. Am J Emerg Med 1997;15:368370.
13. Baumann MH. What size chest tube? What drainage
system is ideal? And other chest tube management
questions. Curr Opin Pulm Med 2003;9:276281.
14. Luketich JD, Kiss MD, Hershey J, et al. Chest tube
insertion: a prospective evaluation of pain management.
Clin J Pain 1998;14:152154.
15. Coulter TD, Maurer JR, Miller MT, Mehta AC. Chest
wall arteriovenous stula: an unusual complication after
chest tube placement. Ann Thorac Surg 1999;67:849
850.
16. Verdigo RJ, Cea JG, Campero M, Castillo JL. Pain and
temperature. In Goetz CG, Pappert EJ (eds): Textbook of
Clinical Neurology, 2nd ed. Philadelphia: Saunders, 2003;
p 351.
17. Lois M, Noppen M. Bronchopleural stulas: an overview
of the problem with special focus on endoscopic manage-
ment. Chest 2005;128:39553965.
18. John S, Jacob S, Piskonowski T. Bronchocutaneous stula
after chest-tube placement: a rare complication of tube
thoracostomy. Heart Lung 2005;34:279281.
19. Taub PJ, Lajam F, Kim U. Erosion into the subclavian
artery by a chest tube. J Trauma 1999;47:972979.
20. Moskal TL, Liscum KR, Mattox KL. Subclavian artery
obstruction by tube thoracostomy. J Trauma 1997;43:
368369.
21. Shapira OM, Aldea GS, Kupferschmid J, Shemin RJ.
Delayed perforation of the esophagus by a closed thora-
costomy tube. Chest 1993;104:18971898.
22. Abad C, Padron A. Accidental perforation of the left
ventricle with a chest drainage tube. Tex Heart Inst J
2002;29:143.
23. Hesselink DA, Van Der Klooster JM, Bac EH, et al.
Cardiac tamponade secondary to chest tube placement.
Eur J Emerg Med 2001;8:237239.
24. Barak M, Iaroshevski D, Ziser A. Rapid atrial brillation
following tube thoracostomy insertion. Eur J Cardiothorac
Surg 2003;24:461462.
25. Williams O, Greenough A, Mustafa N, et al. Extubation
failure due to phrenic nerve injury. Arch Dis Child Fetal
Neonatal Ed 2003;88:7273.
26. Collop NA, Kim S, Sahn S. Analysis of tube thoracostomy
performed by pulmonologists at a teaching hospital. Chest
1997;112:709713.
27. Baumann MH, Strange C, Heffner JE, et al. Management
of spontaneous pneumothorax. An American College of
Chest Physicians Delphi consensus statement. Chest 2001;
119:590602.
28. Antony VB, Loddenkemper R, Astoul P, et al. Manage-
ment of malignant pleural effusions. Am J Respir Crit
Care Med 2000;162:19872001.
29. Colice GL, Curtis A, Deslaurier B, et al. Medical and
surgical treatment of parapneumonic effusions. An
evidence-based guideline. Chest 2000;118:1158
1171.
30. Konstantakos AK. A simple and effective method of
preventing inadvertent occlusion of chest tube drains: the
corrugated tubing splint. Ann Thorac Surg 2005;79:107
111.
31. Gordon AH, Grant GP, Kaul SK. Reexpansion pulmonary
edema after resolution of tension pneumothorax in the
contralateral lung of a previously lung injured patient. J
Clin Anesth 2004;16:289292.
32. Sherman SC. Reexpansion pulmonary edema: a case report
and review of the current literature. J Emerg Med 2003;
24:2327.
33. Mahfood S, Hix WR, Aaron BL, et al. Reexpansion
pulmonary edema. Ann Thorac Surg 1988;45:340
345.
12
Paracentesis
Stacy Loeb, MD and Stephen R. T. Evans, MD
INTRODUCTION
A myriad of clinical conditions can lead to the develop-
ment of ascites. Abdominal paracentesis is both diagnostic
and therapeutic and can aid in the differential diagnosis.
Although in the United States, the majority of cases are
now caused by alcoholic liver disease, other common
causes include infection, malignancy, congestive heart
failure, and nephrotic syndrome. Paracentesis allows the
peritoneal uid to be sent for analysis. The uid is con-
sidered sterile if there are fewer than 250 polymorpho-
nuclear leukocytes/mm3.1
For patients with new-onset ascites, a useful calculation
is the serumascites albumin gradient (SAAG), which can
help distinguish between some of the more common etio-
gies.2 Paracentesis can also be useful to evaluate a patient
with known ascites for the development of spontaneous
bacterial peritonitis.
Not only is paracentesis a critical diagnostic tool, but it
also provides therapeutic benet. Ascites can cause sequelae
ranging from early satiety, abdominal pain, fullness, and
umbilical hernias to shortness of breath and adverse effects
on cardiovascular function.3,4 Paracentesis has been shown
to remove ascitic uid more rapidly than diuretics,5 thus
providing symptomatic relief for the patient.
INDICATIONS
Abdominal ascites
Diagnostic
Therapeutic
OPERATIVE STEPS
Step 1 Prep and drape in supine position
Step 2 Inspect for entry site
Step 3 Inject local anesthetic agent
Step 4 Use appropriate needle/kit to withdraw uid
Step 5 Remove needle and apply sterile dressing
Step 6 Monitor vital signs and labs following the
procedure
OPERATIVE PROCEDURE
The patient should be encouraged to empty the bladder
before paracentesis. It is also useful to document baseline
vital signs, serum chemistries, and complete blood count
prior to the procedure. Paracentesis is most commonly
performed with the patient in a supine position. Strict
adherence to sterile technique should be exercised when
draping and preparing the abdominal area. The abdomen
should be inspected and percussed for an appropriate
entry site. In addition, many institutions, including our
own, use ultrasound routinely for localization. Local anes-
thesia (such as lidocaine) is then administered to the skin
and subcutaneous tissues. Depending upon physician
preference, patient characteristics such as abdominal girth
and the volume of ascites present, a variety of different
needles, catheters, or kits may be used to withdraw the
uid. Drainage can take up to several hours. Once the
drainage begins to taper off, the abdominal position may
be slightly shifted to facilitate the drainage of any residual
areas. When the aspiration is complete, the needle or
catheter can be removed, and sterile 4 4 dressings taped
securely over the area. Blood pressure, heart rate, serum
chemistries (with particular attention to sodium and
creatinine), and complete blood count (to monitor the
hematocrit) should be obtained after the procedure.
Failed Attempt to Localize Ascitic Fluid
Consequence
If a needle is placed into the abdomen and no ascitic
uid can be withdrawn, the patient is subject to the
morbidity of a needle stick without any of the diagnos-
tic or therapeutic benet. Furthermore, the patient may
then need a second procedure.
Grade 1 complication
Prevention
Some authors recommend using a needle insertion site
in the midline,1 whereas others advocate a left lower
quadrant insertion site.4,6 Paracentesis has also been
successfully performed via a right lower quadrant or
infraumbilical insertion site. Regardless, percussion
should be utilized to help select the most appropriate
 144 SECTION II: BEDSIDE PROCEDURES
Umbilical hernia
Surgical scar
Figure 121 Anatomical obstacles/areas to avoid during paracentesis.
site. If it is difcult to localize the area of dullness with
percussion, ultrasound should be employed to help
guide the site selection. In modern intensive care units
and surgical oors, the liberal use and wide availability
of ultrasound should facilitate its routine use in this
setting as well.
Another suggestion for difcult cases is to reposition
the patient. Although paracentesis is traditionally per-
formed with the patient lying semirecumbent, a hand-
knee position may be used instead.7 If the patient is unable
to maintain this position, he or she can be positioned
prone between two beds with the physician performing
the tap from the oor beneath.
Failure due to Inappropriate Needle Selection
Consequence
Attempts to perform paracentesis may not be successful
owing to improper needle selection. Based upon the
body habitus or the quantity of uid to be removed,
the likelihood of success may depend upon the equip-
ment used. With a small-gauge needle, the potential
for complications is minimized. Conversely, larger
needles permit faster drainage but increase the risk of
complications. Thus, these risks and benets should be
carefully weighed.
Grade 1 complication
Prevention
A variety of metal needles have been used to perform
routine paracentesis, typically ranging in size from 16
to 22 gauge.1,4 Although in an average-sized patient, a
1.5-inch (3.8-cm) needle is generally sufcient, for
obese patients, a 3.5-inch (8.9-cm) needle may be nec-
essary to successfully penetrate the pannus. For large-
volume paracentesis, other options include multiple-hole
Bowel with
adhesions
Neurogenic
full bladder
blunt cannulas with sharp removable inner trocars8 or
a 10-Fr Teon peritoneal dialysis catheter, which can
be connected to a Foley bag and drained to gravity.6
Distorted Anatomy Leading to Perforation of
Adjacent Organ
Consequence
The bowel, bladder, and pregnant uterus are the ana-
tomic obstacles most commonly encountered when
performing paracentesis (Fig. 121). Whereas under
normal circumstances, the intestine tends to oat away
from the advancing paracentesis needle, the presence
of adhesions or other anatomic impediments can
prevent this from occurring. The bladder is more likely
to be breached in cases of neurogenic bladder or other
causes of distention. An abnormal position of abdomi-
nal structures could lead to a failed attempt to localize
uid or a more difcult needle placement. It could also
lead the operator to inadvertently traverse adjacent
organs or structures, potentially leading to further
complications. In one large series of diagnostic para-
centeses, two bowel perforations were reported.9
Grade 15 complication
Repair
Possible need for laparotomy/surgical repair.
Prevention
Before paracentesis is performed, the abdomen should
be inspected for any surgical scars, and if possible, the
needle should be introduced away from such areas.10
In cases in which complicated anatomy is suspected or
in pregnant patients, ultrasound should be used to
guide the paracentesis. For neurogenic bladder, cath-
eterization can be performed to empty the bladder
prior to the paracentesis.

Infection
The association between paracentesis and an increased risk
of infection is controversial. In a randomized, controlled
trial, Runyon and coworkers11 compared the levels of
complement and opsonic activity between patients under-
going medical diuretic therapy and those receiving daily
therapeutic paracentesis. Serum levels of complement C3
and C4 were stable in the paracentesis group, whereas both
serum and ascitic uid levels of C3 signicantly increased
after diuretic management. Overall, opsonic activity was
unchanged by paracentesis, but it increased with diuretics
(presumably through the effects of uid concentration).
Although the lack of increase in opsonic activity theoreti-
cally could increase the risk of infection after paracentesis
compared with diuretics alone, there was no difference in
the incidence of spontaneous bacterial peritonitis between
the two groups in this or other studies.
In a separate study, Runyon1 compared the frequency
of infected uid aspirate between initial and repeat para-
centeses during a patients hospital stay and found no
difference in the presence of infected ascites in repeat
paracenteses. Thus, the author concluded that paracente-
sis does not lead to an increased risk of peritonitis.
Consequence/Prevention
No evidence exists that paracentesis considerably
increases the risk of peritonitis in patients with ascites.
Moreover, the presence of suspected spontaneous bacte-
rial peritonitis should not be considered a contraindica-
tion to paracentesis. In fact, paracentesis is highly useful
in the setting of infection to enable both susceptibility
testing and the use of culture-specic antibiotics.
Grade 1 complication
Bleeding
Because alcoholic liver disease is the most common
etiology of ascites, many of the patients undergoing
paracentesis are coagulopathic. Several studies have evalu-
ated the safety and risk of bleeding complications in this
population.
Among 242 diagnostic paracenteses performed in
patients with liver disease, Mallory and associates9 reported
4 hemorrhagic complications. Overall, most paracentesis
series report the incidence to be less than 1% to 2%. The
risk of bleeding does not completely subside after the
immediate postparacentesis period. There are also case
reports of delayed hemoperitoneum after large-volume
paracentesis in patients with liver disease.12
Consequence
Although in the majority of cases, bleeding from para-
centesis does not lead to any major long-term sequelae,
nevertheless, severe hemorrhage leading to death has
been reported.13
Grade 15 complication
12 PARACENTESIS 145
Repair
Attempts should be made to stabilize the patient
with uid resuscitation and blood products. However,
if these measures fail, laparotomy may be necessary,
with control of the bleeding vessels. Nonetheless, the
source of bleeding may not be found intraoperatively,
and the surgery itself could lead to further decompen-
sation in these patients. Therefore, the selection
of therapy should be guided by the specic clinical
situation.
Prevention
Some authors have recommended the use of prophy-
lactic blood products for patients with coagulopathies
prior to undergoing paracentesis. However, McVay
and colleagues14 found that even in patients with mild
to moderate coagulopathies, the frequency of serious
bleeding complications was extremely low, and they
concluded that the use of prophylactic transfusions is
not warranted. In their study, the only subgroup with
a signicantly greater risk of bleeding were patients
with a markedly elevated serum creatinine. In addition,
if abdominal veins are engorged secondary to the alco-
holic liver disease, such areas should be avoided, and
ultrasound guidance is advisable. We conclude that
prophylactic transfusions are unwarranted, because
bleeding complications are so infrequent even in the
presence of coagulopathy.
Fluid and Electrolyte Imbalance
In patients undergoing large-volume paracentesis (>5 L),
some reports have suggested a risk of triggering an
acute reduction in intravascular volume or electrolyte
abnormalities.
Consequence
In 18 patients undergoing large-volume paracentesis,
Kao and coworkers15 found no signicant difference in
pre- and postprocedure sodium, blood urea nitrogen,
hematocrit, or postural systolic blood pressure.15 Pinto
and associates4 measured plasma volume using a dilu-
tion method involving 125I-labeled human serum
albumin in 12 patients undergoing large-volume para-
centesis. They did not nd any difference in the mean
plasma volume, serum sodium, creatinine, or blood
urea nitrogen at 24 and 48 hours after the procedure
as compared with preparacentesis levels. Nevertheless,
in large hepatology services, overaggressive paracentesis
has led to severe hypotension and death (personal
communication, 2007).
Grade 15 complication
Repair
Aggressive uid resuscitation; monitor and replete
electrolytes.
 146 SECTION II: BEDSIDE PROCEDURES
Prevention
Simple steps for prevention are to establish a good uid
and electrolyte balance prior to performing the para-
centesis. Furthermore, the paracentesis should be
limited to removing enough uid for symptomatic
relief and diagnostic purposes, without being overzeal-
ous. Albumin may also be useful with paracentesis in
some cases, taking into account factors such as the
presence or absence of peripheral edema and the volume
of uid removed.6
Ascitic Fluid Leak
In a series of 52 patients undergoing 73 large-volume
paracenteses, Wilcox and colleagues6 reported that the
most common complication was ascitic uid leak in 5
procedures (7%). In all cases, the leak was self-limited.
Nevertheless, in 2 patients the drainage persisted for a
few days.
Consequence
All cases of ascitic uid leak in the literature have been
self-limited.
Grade 1 complication
Repair
Although in most paracenteses, a sterile 4 4 dressing
is sufcient to cover the puncture site, in the presence
of a leak, additional dressings may be needed. Wilcox
and colleagues6 recommended placing an ostomy bag
over the site until the drainage ceases.
Prevention
It is possible that the use of peritoneal dialysis catheters
led to the increased rate of ascitic uid leakage in the
series of Wilcox and colleagues6 and that there is less
risk with smaller-bore needles. However, it is also pos-
sible that other authors simply did not report this as a
complication. Another suggestion for prevention is to
position the patient opposite to the paracentesis site for
a period of time after the procedure.6
Other Complications
In a prospective series of 229 abdominal paracenteses
performed on 125 patients, Runyon1 reported 1 abdomi-
nal wall hematoma requiring transfusion and 2 that did
not require transfusion. Additional morbidities that have
been reported in association with paracentesis include
scrotal edema (grade 1) and retained catheter fragments
left in abdomen9 (grade 2).
CONCLUSIONS/CLINICAL PEARLS
Use sterile technique.
Include routine use of ultrasound for localization.
Make careful needle selection.
Avoid anatomic obstacles (e.g., surgical scars, varices).
Monitor uid and electrolyte status both before and
after the procedure.
REFERENCES
1. Runyon BA. Paracentesis of ascitic uid. A safe procedure.
Arch Intern Med 1986;146:22592261.
2. Pare P, Talbot J, Hoefs JC. Serum-ascites albumin
concentration gradient: a physiologic approach to the
differential diagnosis of ascites. Gastroenterology 1983;85:
240244.
3. Angueira CE, Kadakia SC. Effects of large-volume
paracentesis on pulmonary function in patients with tense
cirrhotic ascites. Hepatology 1994;20(4 pt 1):825828.
4. Pinto PC, Amerian J, Reynolds TB. Large-volume
paracentesis in nonedematous patients with tense ascites:
its effect on intravascular volume. Hepatology 1988;8:
207210.
5. Gines P, Arroyo V, Quintero E, et al. Comparison of
paracentesis and diuretics in the treatment of cirrhotics
with tense ascites. Results of a randomized study. Gastro-
enterology 1987;93:234241.
6. Wilcox CM, Woods BL, Mixon HT. Prospective evalua-
tion of a peritoneal dialysis catheter system for large
volume paracentesis. Am J Gastroenterol 1992;87:1443
1446.
7. Lawson JD, Weissbein AS. [The puddle sign; an aid in the
diagnosis of minimal ascites.] N Engl J Med 1959;260:
652654.
8. Shaheen NJ, Grimm IS. Comparison of the Caldwell
needle/cannula with Angiocath needle in large volume
paracentesis. Am J Gastroenterol 1996;91:17311733.
9. Mallory A, Schaefer JW. Complications of diagnostic
paracentesis in patients with liver disease. JAMA 1978;
239:628630.
10. Runyon BA. Patient selection is important in studying the
impact of large-volume paracentesis on intravascular
volume. Am J Gastroenterol 1997;92:371373.
11. Runyon BA, Antillon MR, Montano AA. Effect of diuresis
versus therapeutic paracentesis on ascitic uid opsonic
activity and serum complement. Gastroenterology 1989;
97:158162.
12. Martinet O, Reis ED, Mosimann F. Delayed hemoperito-
neum following large-volume paracentesis in a patient
with cirrhosis and ascites. Dig Dis Sci 2000;45:357
358.
13. Pache I, Bilodeau M. Severe haemorrhage following
abdominal paracentesis for ascites in patients with liver
disease. Aliment Pharmacol Ther 2005;21:525529.
14. McVay PA, Toy PT. Lack of increased bleeding after
paracentesis and thoracentesis in patients with mild
coagulation abnormalities. Transfusion 1991;31:164
171.
15. Kao HW, Rakov NE, Savage E, Reynolds TB. The effect
of large volume paracentesis on plasma volumea cause
of hypovolemia? Hepatology 1985;5:403407.
Section III
GASTROINTESTINAL
SURGERY
Stephen R. T. Evans, MD
Reason and free inquiry are the only effectual agents against error.
Thomas Jefferson

STOMACH, DUODENUM AND

SMALL BOWEL

13
Open Gastrostomy Feeding Tube
Placement and Percutaneous
Endoscopic Gastrostomy
Tube Placement
Rebecca Evangelista, MD and
Eleanor Faherty, MD

INTRODUCTION addressed in this chapter. Most retrospective studies have

Gastric tube placement is a common procedure for the
delivery of supplemental or total enteral nutrition and for
drainage in cases of distal obstructing masses. A number
of approaches are available depending on the patients
previous surgical history, comorbidities, and reason for
requiring tube placement. Open gastrostomy placement
by Stamm and Janeway techniques as well as percutaneous
endoscopic gastrostomy (PEG) tube placement are
shown little or no statistical difference in the complication
rates between these procedures. The most serious compli-
cation reported is tube dislodgement, with all other com-
plications falling into the minor category.1 Reported
overall complication rates range from 9% to 46%, in which
a vast majority are minor complications.15 Most steps
discussed in this chapter are related to reducing risk of
tube dislodgement in the early and late postoperative
periods and reduction in risk of visceral injury during each
 148 SECTION III: GASTROINTESTINAL SURGERY

procedure. Choosing to perform a Janeway gastrostomy
with gastric stoma maturation can be the best choice in
those cases in which early tube dislodgement is more
likely, in cases of signicant mental status changes, essen-
tially avoiding all related and subsequent complications.
an open gastrostomy tube placement. Occasionally, a left
subcostal incision can be used. Complications related to
laparotomy incisions are discussed in Section I, Chapter
7, Laparoscopic Surgery.

Mobilization of the Stomach and Lysis

INDICATIONS of Adhesions
Bowel Perforation
Functional dysphagia or other risks for aspiration
Gastric outlet obstruction Consequence
Distal obstructing masses Leak from the injured stomach, small bowel, or trans-
Proximal obstructing masses verse colon, leading to postoperative peritonitis. A
Other poor nutritional states minority of patients will have dense adhesions from
previous surgery or a partially or completely intratho-
racic stomach owing to paraesophageal hernia. The
Open Gastrostomy stomach will require adequate mobilization to allow
the anterior portion along the greater curvature to
Tube Placement approximate the anterior abdominal wall two nger-
breadths below the left costal margin without undue
tension.
OPERATIVE STEPS
Grade 3/4 complication
OPEN STAMM GASTROSTOMY TUBE Repair
Two-layer suture repair of all full-thickness injuries.
Step 1 Upper midline incision
Single-layer suture repair of all serosal tears.
Step 2 Mobilization of the stomach
Step 3 Placement of the pursestring suture in the ante- Prevention
rior stomach The position of the stomach must be fully visualized
Step 4 Gastrostomy through an adequate fascial incision and any degree of
Step 5 Placement of the gastrostomy tube into the herniation directly visualized. Sharp dissection should
stomach through the abdominal wall be used for lysis of adhesions and cautery avoided to
Step 6 Suturing the anterior stomach to the peritoneum reduce the risk of delayed thermal perforation.
around the tube tract and insertion site
Step 7 Closure of the midline incision
Step 8 External suturing of the tube to the anterior Placement of the Pursestring Suture in
abdominal wall the Anterior Stomach
OPEN JANEWAY GASTROSTOMY TUBE Inadequate Suture Thickness
Step 1 Upper midline incision Consequence
Step 2 Mobilization of the stomach Tear of the gastric wall with pull-through of the suture.
Step 3 Creation of the gastric tube along the anterior This can result in an immediate or delayed perforation
stomach in the stomach, allowing for potential leak if not
Step 4 Creation of the tract through the anterior repaired adequately. Suture that is visible through the
abdominal wall for the gastric tube serosal surface layer is too shallow, has a higher risk of
Step 5 Maturation of the gastric stoma tear, and should be replaced.
Step 6 Insertion of the gastrostomy tube through the Grade 3 complication
stoma
Step 7 Closure of the midline incision Repair
Two-layer repair and repositioning of the pursestring
OPERATIVE PROCEDURE suture for a separate site of intended tube insertion.

OPEN STAMM GASTROSTOMY Prevention

Upper Laparotomy
Intra-Abdominal Injuries with Midline Incision
To obtain access to and adequate exposure of the stomach,
an upper midline is the standard incision of choice for
Sutures should be placed to a seromuscular thickness
by fully pronating the wrist and driving the needle
perpendicular with an almost immediate supination of
the wrist. If a seromuscular placement cannot be
ensured, a full-thickness bite is adequate.

Gastrostomy in the Center of the Pursestring
Injury to the Posterior Wall of the Stomach
Consequence
Immediate or delayed intra-abdominal leak through
the posterior wall.
Grade 3/4 complication
Repair
Two-layer suture repair from the posterior surface of
the stomach requires exposure of the posterior stomach
through a window into the lesser sac through the gas-
trocolic ligament.
Prevention
Retract the anterior stomach wall with atraumatic
forceps or Babcocks while creating the gastrostomy.
The gastrostomy can also be made by opening the
individual layers of the gastric wall, sequentially retract-
ing each subsequent deeper layer. Avoid prolonged
application of the cautery and using pressure on the
tip of the cautery to create tension while making the
gastrostomy.
Placement of the Gastrostomy Tube into the
Stomach through the Anterior Abdominal Wall
Tube Damage/Inadequate Closure of
Pursestring Sutures
Consequence
Immediate or delayed failure of the balloon to retain
ination. Immediate or delayed leak from or around
the tube. An early consequence of deation of a balloon,
if used, is bleeding from the gastrotomy owing to lack
of tamponade. Leak from the tube early through a hole
in the tube can result in extravasation of tube contents
into the abdomen or along the abdominal wall
tract leading to peritonitis or localized fasciitis,
respectively.
Grade 1/2 complication
Repair
After passing the tube through the tract in the abdom-
inal wall, test a balloon, if used, or ush the tube with
saline and look for a leak. A dilute solution of methy-
lene blue can also be used if damage to the tube is
suspected but unclear with saline ush.
Prevention
After the tract in the anterior abdominal wall is made
with a tonsil clamp use a broader Kelly clamp to pull
the tube through the tract. Also clamp the entire tube
rather than feeding the lumen of the tube onto one
tine of the clamp to avoid damage to the tube as it is
being pulled through the layers of the abdominal
wall.
13 GASTROSTOMY TUBE PLACEMENT 149
Suturing the Anterior Stomach to the
Peritoneum around the Tube Tract and
Insertion Site
Tension and Tearing of Stomach around
Gastrostomy Site/Loss of Tube Tract
Consequence
Leak around the tube insertion site. Slippage of stomach
away from the anterior abdominal wall or tube from
within the stomach. Early, this can lead to free intra-
abdominal leak of gastric contents and inability to
replace the tube by uoroscopic guidance.
Grade 3 complication
Repair
Fluoroscopic guidance to replace a slipped tube may be
possible 3 to 5 days after placement. Seldinger tech-
nique can be used to identify the tract and determine
whether access to the stomach is present. If access to
the stomach cannot be veried, open exploration and
replacement of the tube or repair of the original gas-
trotomy will be necessary.
Prevention
Place multiple interrupted sutures of nonabsorbable
material around the tube site. Be sure that the
sutures are placed seromuscular or full thickness in the
stomach and obtain adequate purchase of each suture
on the peritoneum. Ensure that the balloon is deated
during this step and inated before closing the
abdomen.
Closure of the Midline Incision
Injury to Intra-Abdominal Structures/Dehiscence
See Section I, Chapter 7, Laparoscopic Surgery.
External Suturing of the Tube to the Anterior
Abdominal Wall
Tube Dislodgement
Consequence
Slippage of stomach from the anterior abdominal wall
with subsequent leak and loss of percutaneous access
to the stomach.
Grade 3 complication
Repair
See Suturing the Anterior Stomach to the Peritoneum
around the Tube Tract and Insertion Site, earlier.
Replace any sutures that have pulled through the skin
or been inadvertently cut.
Prevention
Place several permanent interrupted sutures around the
tube and/or external bumper to the skin. Air knots
 150 SECTION III: GASTROINTESTINAL SURGERY
may keep the skin from necrosis, but skin sutures should
be full thickness to avoid tearing through. Abdominal
binders can also be placed for the rst week to mini-
mize access to the tube before the tract becomes
epithelialized.
OPEN JANEWAY GASTROSTOMY
For upper midline incision and mobilization of the
stomach, see Open Stamm Gastrostomy, earlier.
Creation of the Gastric Tube along the Anterior
Stomach Wall
Inadequate Length or Width of
Gastric Tube/Inadequate Blood Supply to
Gastric Tube
Consequence
Inability to evert a stoma at the skin surface or
undue tension on the gastric tube to evert the
stoma. If the tube is not developed from the midante-
rior stomach toward the greater curvature, there may
be too much tension on the gastric tube through
the abdominal wall or poor blood supply along the
staple line.
Grade 1 complication
Repair
If the tube appears dusky or cannot deliver com-
pletely with 1 cm above the skin, a new tube needs
to be created or extended toward the greater
curvature.
Prevention
Start the creation of the gastric tube in the midpor-
tion of the anterior gastric wall and remain parallel
to the greater curvature. Based on the thickness of
the abdominal wall, estimate the length needed to
ensure a 1-cm extension above the skin. Maintain a
tube diameter of approximately 1.5 cm for the full
length.
Creation of the Tract through the Anterior
Abdominal Wall for the Gastric Tube
Inadequate Position/Inadequate Diameter
of Tract
Consequence
Inability to place a tube of adequate diameter through
the gastric tube into the stomach, undue tension on
the base of the gastric tube, or impingement of tube
through too narrow a tract.
Grade 3 complication
Repair
Lengthen the gastric tube to allow for tension-free
passage and reduce torque through the abdominal wall.
Enlarge the diameter of the fascial opening.
Prevention
Complete the creation of the gastric tube prior to
making the tract through the abdominal wall to allow
for more accurate placement of the tract. The tract
should be straight through the abdominal wall up from
the base of the gastric tube and should be at least 2 to
3 cm below the left costal margin.
Maturation of the Gastric Stoma
Inadequate Eversion of Gastric Tube
Consequence
Leak of gastric or tube contents into abdominal wall
owing to slippage of the gastric tube end below the
skin surface. Inability to pass tube into the stomach.
Grade 3 complication
Repair
Increase the length of the gastric tube and resuture the
circumference of the gastric tube.
Prevention
Place interrupted sutures from the gastric tube end,
seromuscular through the gastric tube 1 cm deep to the
end and nally through deep dermis. This will ensure
complete eversion of the end of the gastric tube.
Insertion of the Gastrostomy Tube through
the Stoma
Inadequate Positioning below the Level of
the Abdominal Wall
Consequence
Leak and inadequate nutrition delivery.
Grade 2 complication
Repair
Release any balloon at the end of the tube, remove,
and replace after lubricating the tip. A contrast study
can be done if there is any question about complete
tube advancement into the stomach below the level of
the posterior fascia.
Prevention
A contrast study can be done if there is any question
about complete tube advancement into the stomach
below the level of the posterior fascia.
Closure of the Midline Incision
See Open Stamm Gastrostomy, earlier.
 13 GASTROSTOMY TUBE PLACEMENT 151

Insufation of the Stomach

Percutaneous Inadequate Distention of the Stomach
Gastrostomy Consequence
Inability to nd the best one-to-one position and/
Tube Placement or pass the angiocatheter percutaneously into the
stomach.
OPERATIVE STEPS Grade 1 complication

Step 1 Insertion of endoscope through the esophagus Repair

into the stomach Close all nonworking ports and cover the insufa-
Step 2 Insufation of the stomach tion button on the scope. Watch as the rugae of the
Step 3 Identication of the one-to-one position on stomach atten as an indicator of the proper amount
the abdominal wall of insufation. Insufate until the stomach grossly
Step 4 Percutaneous insertion of the angiocatheter into distends the anterior abdominal wall. If one-to-one
the stomach position cannot be well dened, convert to an open
Step 5 Endoscopic capture of the guidewire and gastrostomy.
removal
Step 6 Pull-through of PEG tube from the oral cavity Prevention
into the stomach via guidewire Prior to the start of the endoscopy, ensure that all
Step 7 Placement of external bumper and external systems for the scope are in proper working order
anchoring suture including the insufation. Look over the head of the
Step 8 Repeat endoscopy scope and ensure that all instrument ports are capped
or closed while not in use.

OPERATIVE PROCEDURE Identication of One-to-One Position on

Insertion of the Endoscope into the Stomach
Perforation
Consequence
Anywhere along the path of the endoscope, a visceral
tear and perforation can occur. Leak from an esopha-
geal tear can be into the thorax or the abdomen
depending on the location of the perforation. Perfora-
tion of the stomach is rare but possible. Although rare,
it can be fatal.6
Grade 3/4 complication
Repair
If found early after endoscopy, exploration and repair
of the perforation may be necessary by either open
surgical repair or esophageal stent placement.7 If diag-
nosed late, many esophageal perforations can be treated
with a course of total parenteral nutrition and nothing
by mouth.
the Abdominal Wall
Colonic or Small Bowel Injury/Placement of PEG
Tube through Bowel
Consequence
Peritonitis from leak, sepsis, bowel obstruction.
Grade 3 complication
Repair
Exploratory laparotomy and resection of involved
bowel with possible temporary colostomy.
Prevention
Look for the one-to-one position where minimal com-
pression on the anterior abdominal wall shows obvious
depression of the stomach on endoscopy. In addition,
transilluminating can show the end of the scope clearly
through the anterior abdominal wall indicating minimal
tissue between the scope and the skin and proper loca-
tion for tube placement (Fig. 131).

Prevention Percutaneous Insertion of the Angiocatheter

Maintain the view of the lumen in the center of the into the Stomach
scope at all times. Recognize the appearance of bright
Laceration of Short Gastric Vessels/Injury
white, signifying the end of the scope up against
to Bowel
the visceral wall. Use of small amounts of insufation
will also help open the lumen ahead of the scope, allow- Consequence
ing for maintaining the proper view during scope Ongoing intra-abdominal bleeding.
advancement. Grade 2/3/4 complication
 152 SECTION III: GASTROINTESTINAL SURGERY

Colon
Rib

Liver

Small intestine
A Stomach Endoscope

Gastrostomy tube
Colon
secured Rib
B

Figure 131 A, Poor one-to-one with a wide gastric indenta-

Liver tion may indicate the presence of transverse colon, omentum, or
small bowel between the abdominal wall and the anterior gastric
wall. B, Example of poor one-to-one palpation with a wide gastric
Small intestine indentation (arrow). C, Example of percutaneous endoscopic gas-
trostomy (PEG) placement through intervening tissue if good one-
C Stomach
to-one palpation is not identied.

Repair guidewire. Laceration of the tongue will result in local

Exploratory laparotomy and suture ligation of bleeding pain and bleeding.
vessels. Grade 1 complication

Prevention
Establish proper one-to-one position and do not go
below two ngerbreadths under the costal margin,
increasing the risk of needle insertion at the greater
curvature rather than on the anterior surface of
the stomach. Do not attempt multiple passes of the
angiocatheter. If good one-to-one position cannot be
established or two passes of the angiocatheter are
unsuccessful, convert the procedure to an open gastros-
tomy placement.
Endoscopic Capture of the Guidewire and
Removal through the Mouth
Loss of Guidewire/Laceration of Tongue
Consequence
Inability to attach and pull the PEG tube into place,
requiring repeat endoscopy to locate the end of the
Repair
Repeat placement of the endoscope to locate the end of
the guidewire to recapture. If the end is not seen or it
is not possible to safely grasp the end within the esoph-
agus, pull the wire back into the stomach under direct
visualization, reinsufate, and regrasp the guidewire. A
tongue laceration from this step will very rarely require
any specic treatment other than direct pressure and
suctioning of the mouth until the bleeding ceases.
Prevention
When grasping the wire, be sure to allow sufcient
guidewire through the loop of the grasper. Assign a
single person to maintain a tight grasp on the guidewire
until it is retrieved from the grasper after pulling the
entire scope and grasper from the mouth. To avoid
tongue laceration, minimize the amount of movement
of the guidewire after pulling through the mouth (Fig.
132).

Figure 132 Grasp the guidewire well beyond the end to
avoid loss of the wire during delivery through the esophagus and
oropharynx.
Pull-through of the PEG Tube into
the Stomach and through the Abdominal Wall
via the Guidewire
Laceration of Tongue/Loss of PEG from
Guidewire
For laceration of the tongue, see Endoscopic Capture
of the Guidewire and Removal through the Mouth,
earlier.
Consequence
Loss of the tract as the guidewire is pulled through the
abdominal wall without the PEG tube.
Grade 1 complication
Repair
Restart the procedure from Step 1, Insertion of
the Endoscope through the Esophagus into the
Stomach.
Prevention
Prior to pulling the PEG through the esophagus and
stomach, ensure that the guidewire is securely attached
to the PEG tube and manually guide them as a unit
into the posterior oropharynx before pulling into the
stomach and through the abdominal wall. Also ensure
that the stab incision in the abdominal skin is long
enough to accommodate the diameter of the PEG tube
to avoid undue resistance while pulling through the
abdominal wall.
13 GASTROSTOMY TUBE PLACEMENT 153
Figure 133 Repeat endoscopy is done to ensure adequate
approximation of the PEG button to the gastric wall and good
hemostasis.
Placement of the External Bumper and
the External Anchoring Suture
Abdominal Wall Necrosis/Bleeding/Accidental
Loss of PEG Tube
Consequence
Tight placement of the bumper can lead to abdominal
wall abscess and/or necrotizing fasciitis around the
tube site. Loose placement can allow for bleeding
around the tube insertion site from the gastric
mucosa.
Grade 2/3 complication
Repair
Loosen the bumper at the bedside as soon as tight
placement is recognized. Local wound care may be all
that is necessary. However, with worsening necrosis,
operative wide dbridement may be necessary. If
ongoing blood loss is suspected and a loose position is
recognized, the bumper can be tightened at the bedside.
Endoscopy can conrm this problem and guide tight-
ening to a point of tamponade.
Prevention
In most patients, the bumper position should be around
3 cm on the tube at the exit point from the abdominal
wall. Repeating the endoscopy after tube securing can
conrm adequate tamponade.
 154 SECTION III: GASTROINTESTINAL SURGERY
Repeat Endoscopy
This is done primarily to ensure proper tension of the PEG
tube on the gastric wall to promote hemostasis and
evaluate for any injury (Fig. 133). See Insertion of the
Endoscope into the Stomach, earlier.
REFERENCES
1. MacLean AA, Alverez NR, Davies JD, et al. Complications
of percutaneous endoscopic and uoroscopic gastrostomy
tube insertion procedures in 378 patients. Gastroenterol
Nurs 2007;30:337341.
2. Mller P, Lindberg CG, Zilling T. Gastrostomy by various
techniques: evaluation of indications, outcome, and
complications. Scand J Gastroenterol 1999;34:10501054.
3. Bankhead RR, Fisher CA, Rolandelli RH. Gastrostomy
tube placement outcomes: comparison of surgical, endo-
scopic, and laparoscopic methods. Nutr Clin Pract 2005;
20:607612.
4. Hoffman MS, Cardosi RJ, Lemert R, Drake JG. Stamm
gastrostomy for postoperative gastric decompression in
gynecologic oncology patients. Gynecol Oncol 2001;82:
360363.
5. Rustom IK, Jebreel A, Tayyab M, et al. Percutaneous
endoscopic, radiological and surgical gastrostomy tubes: a
comparison study in head and neck cancer patients. J
Laryngol Otol 2006;120:463466.
6. Freeman RK, Van Woerkom JM, Ascioti AJ. Esophageal
stent placement for the treatment of iatrogenic
intrathoracic esophageal perforation. Ann Thorac Surg
2007;83:20032007; discussion 20072008.
7. Panos MZ, Reilly H, Moran A, et al. Percutaneous
endoscopic gastrostomy in a general hospital: prospective
evaluation of indications, outcome, and randomised
comparison of two tube designs. Gut 1994;35:1551
1556.
14
Open Jejunostomy Tube Placement
Eleanor Faherty, MD and
Rebecca Evangelista, MD
INTRODUCTION
Enteral nutrition is the preferred method of feeding
patients who are unable to meet their caloric needs through
the conventional oral route. Feeds are most commonly
initiated via the stomach, but the jejunum is an acceptable
alternative. Jejunal feeding tubes are often placed in
patients who are at increased risk of aspiration of gastric
contents. It is also an option when the stomach is not
suitable for a gastrostomy tube because of previous surgery,
distal obstruction, or disease. Jejunostomy tubes are also
often placed during extensive enteric reconstructions in
which delayed oral intake is anticipated. Such tubes provide
distal access for enteral nutrition and help to avoid the
need for parenteral nutrition and prolonged vascular
access.1
INDICATIONS
High risk for aspiration
Gastric outlet obstruction
Gastric dysmotility (i.e., gastroparesis)
Previous gastric resection or gastric bypass
Status after esophagogastrectomy
Inability to place percutaneous endoscopic gastrostomy
(PEG) tube
Enteral access needed after extensive surgical
procedure
Long-term enteral access for chemotherapy patients2,3
OPERATIVE STEPS 2
Step 1 Upper midline incision
Step 2 Identication of the jejunum approximately
20 cm distal to ligament of Treitz
Step 3 Placement of pursestring suture in antimesen-
teric side of jejunum
Step 4 Jejunostomy
Step 5 Placement of jejunostomy tube into jejunum
through abdominal wall*
Step 6 Suturing of jejunal wall to anterior abdominal
wall around tube insertion site
Step 7 Close midline incision
Step 8 External suturing of tube to anterior abdominal
wall
OPERATIVE PROCEDURE
Upper Midline Incision
Intra-Abdominal Injuries with Midline Incision
To obtain access and adequate exposure of the jejunum
for an open jejunostomy tube placement, an upper midline
incision is the standard choice. Care should be taken if the
patient has had prior laparotomies and, thus, has resultant
scar tissue. Complications related to laparotomy incisions are
discussed in Section I, Chapter 7, Laparoscopic Surgery.
Identication of the Jejunum
Incorrect Identication of the Ligament of Treitz
If the ligament of Treitz is not identied or is incorrectly
identied, the placement of the jejunostomy tube may not
be in the correct location in the jejunum. Ideal placement
is considered to be approximately 20 to 30 cm distal to
the ligament of Treitz.
Consequence
Malabsorption may result if the tube is placed too dis-
tally. If the tube is too proximal, it is possible that
enteral feeds could reux via the duodenum into the
stomach and possibly cause aspiration.
Grade 2/3 complication
*Some surgeons add a step here to additionally secure tube via the
Witzel technique. To do this, place seromuscular sutures on either
side of feeding tube to wrap about 5 cm of tube proximally with
jejunal wall. Potential pitfalls with this technique are intestinal
obstruction owing to excessive imbrication of the bowel wall
circumference.
 156 SECTION III: GASTROINTESTINAL SURGERY
Repair
If incorrect placement of the tube is noticed intraop-
eratively, the tube may be removed and the jejunos-
tomy closed primarily. If proximal or distal placement
is suspected from clinical factors, a contrast study may
be performed to conrm tube location. If the study
conrms either proximal or distal placement and the
patient is not tolerating enteral feeding, a new tube
should be placed.
Prevention
Correct identication of the ligament of Treitz will aid
in proper tube placement. Locating the ligament is
most easily accomplished by reecting the transverse
colon and omentum superiorly and following the trans-
verse colon mesentery to its posterior origin. The liga-
ment of Trietz should be visualized and palpated just
to the left of midline in its posterior location.
Placement of the Pursestring Suture in
the Antimesentric Jejunum
Inadequate Suture Thickness
Consequence
Tear of the jejunal wall with pull through of the
suture. This can result in an immediate or delayed full-
thickness tear in the jejunal wall, allowing for potential
leak.
Grade 2/3 complication
Repair
Primary repair of any jejunal injury and repositioning
of the pursestring suture for tube placement.
Prevention
Pursestring sutures should be anchored in the seromus-
cular layer of the jejunum for adequate strength. Sutures
can be placed by fully pronating the wrist and driving
the needle perpendicular to the tissue with an almost
immediate supination of the wrist. Suture that is visible
through the serosal surface is likely too shallow and has
a higher risk of pulling through the tissue and, thus,
should be replaced.
Jejunostomy in the Center of
the Pursestring Suture
Injury to the Posterior Wall of the Jejunum
Consequence
Immediate or delayed leak through the posterior wall.
Grade 3 complication
Repair
Primary repair of the posterior wall injury.
Prevention
Retraction of the antimesenteric side of the jejunum
with atraumatic forceps will help avoid a posterior wall
injury. Avoid prolonged application of the cautery or
using signicant pressure on the tip of the cautery or
knife when making the jejunostomy.
Mesenteric Hematoma if the Jejunostomy Is
Made Too Close to the Mesentery
Consequence
Bowel ischemia at the associated small bowel, resulting
in bowel necrosis and/or intra-abdominal leak.
Grade 3 complication
Repair
If the hematoma is small and detected intraoperatively,
direct pressure may be sufcient or a small suture liga-
ture to the mesentery may be needed. If the hematoma
is large, or if there are signs of ischemia or stricture of
the jejunum, a resection with primary anastomosis may
be necessary.
Prevention
Careful placement of jejunostomy on the antimesen-
teric side of the jejunum.
Placement of the Jejunostomy Tube into the
Jejunum through the Anterior Abdominal Wall
Failure of the Pursestring to Secure
the Jejunostomy Tube
Consequence
Tube dislodgement and possible intra-abdominal
leak.
Grade 2/3 complication
Repair
If recognized intraoperatively, a new pursestring suture
may be placed to secure the tube. If recognition is
delayed, a repeat laparotomy would be needed for
jejunal repair and new tube placement.
Prevention
Ensure that the pursestring suture is placed in the
seromuscular layer (see earlier). When tying the suture
around the tube, maintain tension to avoid placement
of an air knot.
Injury to the Epigastric Vessels
Consequence
Abdominal wall hematoma and, rarely, pseudoaneu-
rysm of the epigastric artery.
Grade 1/2/3 complication
Repair
Evacuation of hematoma and oversewing of vessels
if active bleeding is still apparent. Surgical excision of
the pseudoaneurysm may be necessary to relieve pain
at the site.
 14 OPEN JEJUNOSTOMY TUBE PLACEMENT
Prevention
Knowledge of the normal and variant anatomy of the
superior and inferior epigastric vessels is essential to
avoiding injury. Placement of the jejunostomy tube at
least 8 cm lateral to the midline should avoid vessel
injury. Also direct visualization of the tube and instru-
ment entry into the abdomen from the peritoneal side
of the abdominal wall will allow identication of the
epigastric vessel course and avoidance of injury.
Suturing of the Jejunal Wall to the Anterior
Abdominal Wall around the Tube Insertion Site
Inadequate Anchoring of the Jejunum to
the Anterior Abdominal Wall
Owing to a high risk of obstruction, most surgeons do
not use tubes with distal balloons in the jejunum. The
tubes are not routinely xed to the small bowel other than
to secure the pursestring sutures. This differs from the
procedure for gastrostomy tubes in that the anchoring
sutures to the anterior abdominal wall are signicant in
jejunostomy tube placement.
Consequence
High tension from the jejunum pulling away from the
anterior abdominal wall can result in tube dislodge-
ment, loss of percutaneous access to the jejunostomy,
and likely intra-abdominal leak.
Grade 3 complication
Repair
Repeat laparotomy for primary repair of the jejunos-
tomy site and new tube placement.
Prevention
Seromuscular sutures in the jejunum should be placed
on four sides of the jejunostomy tube insertion site
to distribute any tension away from the tube. These
sutures should then be securely tied (avoid air knots)
to the internal side of the anterior abdominal wall to
minimize jejunal mobility at the tube insertion site.
157
Closure of the Midline Incision
See Section I, Chapter 7, Laparoscopic Surgery.
External Suturing of the Tube to the Anterior
Abdominal Wall
Tube not Adequately Secured to the External
Abdominal Wall
Consequence
Tube dislodgement.
Grade 2/3 complication
Repair
If this occurs early (<1 wk), an attempt may be made
to replace the tube at same site with wire-guided uo-
roscopy. If the tube is dislodged after a week, it may
be possible to replace the tube into epithelialized tract
and to conrm placement in the jejunum with a con-
trast study. If neither is possible, a repeat laparotomy
will be needed for tube replacement.
Prevention
Use of a xation device is included with some com-
mercially available feeding tubes, or adequate sutures
to the skin covered by a dressing should assist in avoid-
ing tube dislodgement.
REFERENCES
1. Kudsk KA. Clinical applications of enteral nutrition. Nutr
Clin Prac 1994;9:165.
2. Kudsk KA. Enteral nutrition. In Baker RJ, Fisher JE (eds):
Mastery of Surgery, 4th ed. Philadelphia: Lippincott
Williams & Wilkins 2001; pp 8092.
3. Chand B, Ponsky JL. Flexible endoscopy and enteral access.
In Mastery of Endoscopic and Laparoscopic Surgery, 2nd
ed. Philadelphia: Lippincott Williams & Wilkins 2005;
pp 185192.
15
Graham Patch Repair
Babak Sarani, MD and Andrea Badillo, MD
INTRODUCTION
The surgical management of peptic ulcer disease (PUD)
has changed dramatically since the 1970s primarily owing
to the advancement of medical therapy. With the intro-
duction and widespread use of histamine-2 (H2)receptor
blockers, proton pump inhibitors, and effective treatment
of Helicobacter pylori (H. pylori), classic acid-reducing
procedures are rarely performed.1 Despite these pharma-
cologic advances, however, the incidence of perforated
duodenal ulcer has changed little. Therefore, a much
larger proportion of surgery for PUD is emergent.2,3 In
addition to presenting emergently, the typical patient
with perforated PUD (PPUD) is 50 to 60 years of age4,5
with comorbid disease and limited physiologic reserve.
Therefore, the general surgeon must be adept at identi-
fying which of these patients require surgery and how to
perform the necessary procedure(s) and must be familiar
with the pitfalls associated with taking care of such
patients. This chapter discusses repair of duodenal and
juxtapyloric ulcers and excludes other more proximal or
distal ulcers.
Perforated duodenal ulcer disease (DUD) is associated
with a 2% to 10% mortality rate, with septicemia being the
most common cause of death.68 Preoperative shock, per-
foration for greater than 24 hours prior to surgical inter-
vention, and concurrent signicant illness have consistently
been shown to be predictive of mortality, and the presence
of all three risk factors carries a near 100% mortality.7,911
Furthermore, some investigators have found that the
amount and type of uid in the abdomen and the patients
preoperative nutritional status may also be predictive of
mortality.8 Given that up to 50% of perforated ulcers seal
by the time of operation,12 the challenge is to identify
which patients require emergent operation to control the
source of sepsis versus those patients that can be treated
nonoperatively, thereby avoiding the additional morbidity
of a laparotomy.
Omental patch or Graham patch closure of per-
forated duodenal ulcers was rst described in 1929 by
Cellen-Jones13 and by Graham in 1937.14 In its original
description, a tongue of omentum is held in place over
the perforation with suture. More recently, this technique
has been performed using a laparoscopic approach.
Although multiple reports have documented the safety
of laparoscopic repair, no good studies demonstrate the
superiority of this approach.10,1520 Overall, these reports
suggest that there is very little difference in outcome
between patients undergoing laparoscopic or those having
an open approach if the surgeon has advanced laparo-
scopic training and experience. The postoperative ileus,
pain, wound infection rate, and hospital stay are very
similar, and any differences noted may be due to bias
in the trial design. As such, the decision to proceed
laparoscopically should be made based on the surgeons
experience and comfort with one modality versus the
other.
Nonoperative treatment for PPUD can be instituted
in very specic circumstances (Box 151) and includes
antibiotics, treatment for H. pylori, and nasogastric
decompression.12,16,21,22 A contrast study is essential to
conrm that the perforation has sealed because the phys-
ical examination is unreliable for this determination.
Assuming that the perforation has, in fact, sealed, this
group of patients has an expected mortality rate of
35% to 50% owing to the delay in presentation or severity
of comorbid illness(es).23 Of note, patients whose symp-
toms and physiologic status do not improve within 12
hours of the institution of nonoperative therapy require
surgery.12
INDICATIONS
Perforated duodenal ulcer
KEY STEPS 14,17,23
Step 1 Midline incision. Can also use transverse inci-
sion, if desired. Trocar placement if procedure is
to be done laparoscopically
Step 2 Expose area of perforation
Step 3 Irrigate surrounding tissues and spaces
Step 4 Place sutures across the perforation
Step 5 Mobilize tongue of greater omentum on a wide
vascular pedicle
Step 6 Place omentum over the perforation
 160 SECTION III: GASTROINTESTINAL SURGERY
Box 151 Indications for Nonoperative Treatment
Symptoms >48 hr old
No indices of systemic sepsis present
No diffuse peritonitis
Documentation with contrast radiography that the
perforation has sealed
Signicant comorbid conditions rendering the patient
American Society of Anesthesiologists Class 45, if all of
the above conditions are also present
From Donovan AJ, Berne TV, Donovan JA. Perforated duodenal
ulcer: an alternative therapeutic plan. Arch Surg 1998;133:11661171;
Jamieson GG. Current status of indications for surgery in peptic ulcer
disease. World J Surg 2000;24:256258; Berne T, Donovan A.
Nonoperative treatment of perforated duodenal ulcer. Arch Surg
1989;124:830832; and Taylor H. Peptic ulcer perforation treated
without operation. Lancet 1946;2:441444.
Step 7 Secure sutures over the omentum
Step 8 Close fascia and skin. Remove trocars.
OPERATIVE PROCEDURE
Midline Incision
Injury to Visceral Organs
A standard laparotomy incision beginning just caudad
to the xyphoid and ending several centimeters above
the umbilicus is most often used. A transverse incision can
also be used based on the patients previous surgical
history or surgeon preference. Many, though not all,
studies suggest that transverse incisions may be associated
with a lower postoperative hernia rate.2426 Complications
related to midline incision and fascial closure are discussed
separately in Section I, Chapter 5, Anesthesia for the
Surgeon.
Trocar Insertion Injuries
(Laparoscopic Approach)
Trocar placement varies based on surgeon preference
and experience. One approach utilizes a Hassan trocar
in the infraumbilical position, an 11-mm trocar in the
left midclavicular line approximately just above the level
of the umbilicus, and a 5-mm trocar in the right midcla-
vicular line just above the umbilicus. Complications of
trocar insertion are discussed separately in Section I,
Chapter 7.
Exposure of the Area of Perforation and
Irrigation of Surrounding Spaces
Opening of a Sealed Perforation
Consequence
At the time of surgery, tissues in the area have sealed
the duodenal perforation in 50% of cases.12 Disruption
of this closure results in the need for additional manip-
ulation of inamed tissues to re-create a seal over the
defect and may increase the postoperative leak rate.
Grade 2 complication
Repair
See later steps for how to proceed with a Graham patch
repair.
Prevention
Tissues that appear to be adherent to the duodenum
in cases in which no perforation is seen should not be
manipulated. Rather, air or liquid can be gently injected
into the duodenum by nasogastric tube to test the
integrity of the existing seal.
Placement of Sutures across the Perforation
Enlargement of the Perforation
Consequence
An increase in the size of the perforation can amplify
the difculty of repair, with a possible increase in the
postoperative leak rate.
Grade 1 complication
Repair
A slight increase in the size of the perforation does not
require a change in operative technique. A giant duo-
denal defect (>3 cm) may not be amenable to Graham
patch repair.27 In this circumstance, other procedures
such as vagotomy/pyloroplasty, pyloric exclusion with
proximal gastric diversion, or side-to-side duodenoje-
junostomy may be necessary. However, the latter pro-
cedure is very rarely needed in the majority of patients
undergoing surgery for PPUD, even with iatrogenic
enlargement of the perforation. Pitfalls related to anas-
tomoses involving the duodenum are discussed else-
where.
Prevention
Three to four interrupted 3-0 silk sutures are placed
across the perforation. The sutures are inserted approx-
imately 1 cm away from the edge of the perforation to
accommodate the tendency of the suture to pull
through the friable, inamed duodenum. Ideally, all
sutures should be placed through normal intestine,
away from the area of inammation. The needle should
be retrieved and reintroduced from within the perfora-
tion during suture placement so as to place the suture
using two passes of the needle (Figs. 151 and 152).
This minimizes torque or undue force on the duode-
num itself and helps prevent inadvertent worsening of
the perforation.
Stenosis of the Duodenal Lumen
Consequence
Stenosis of the duodenum may result in small bowel
obstruction postoperatively.
Grade 2/3 complication
 15 GRAHAM PATCH REPAIR 161

tum
en
m
O
er
ss
Le

Figure 151 Incorrect placement of sutures across Perforated

duodenal ulcer
the perforation. Passage of the needle across the per-
foration in one pass can result in undue force and
tension, resulting in tearing of the indurated tissue.
The suture should be placed across the perforation MC
using two passes of the needle.

m
ntu
e
Om
er

ss
Perforated Le
duodenal ulcer

A B

C
Figure 152 Correct placement of sutures across the perforation. Placement of the suture and needle across the perforation using two
passes of the needle (A and B) minimizes undue tension across the site and decreases trauma to the indurated tissue. C shows the correct
placement of sutures across the defect.

Repair
Mobilization of the Tongue of the
Sutures that are noted to narrow the lumen of the bowel
Greater Omentum
or that may have apposed the posterior and anterior walls
of the duodenum should be removed and replaced. Necrosis of the Omental Tongue
Prevention Consequence
Utilizing two passes of the needle as described previ- Necrosis of the tongue of the omentum used to fashion
ously decreases the possibility of suturing the posterior a repair can manifest as a postoperative leak with
and anterior walls of the duodenum. subsequent peritonitis and sepsis. This signicantly
 162 SECTION III: GASTROINTESTINAL SURGERY

Mobilized pedicle of
greater omentum
Securing
greater
omentum
over ulcer

Figure 153 Mobilization of the omentum to the perforation. A

wide pedicle must be mobilized to prevent ischemia of the
omentum.
Figure 154 Securing the omentum across the perforation. The
sutures should be tied to keep the omentum in place. Excessively
tight knots will result in ischemia and necrosis of the omentum and
disruption of the repair.
increases the morbidity and mortality associated with
PPUD.28
Grade 3 complication
Repair
Necrosis of the omental tongue is rarely noted intra-
operatively because of the operative time associated
with repair of DUD. However, if noted intraopera-
tively, a separate, better-vascularized portion of the
omentum should be used and the ischemic ap should
be resected.
Prevention
Creating a wide, well-vascularized pedicle on the greater
omentum and placing the omentum over the perfora-
tion in a tension-free manner best prevents this com-
plication (Fig. 153). Similarly, there is no need to
push the omentum into the perforation because this
can strangulate the omentum in a mechanism similar
to that of an incarcerated, strangulated hernia. Figure 155 Securing the omentum across the perforation. The
sutures should be tied to keep the omentum in place. Excessively
tight knots will result in ischemia and necrosis of the omentum and
disruption of the repair.
Placement of the Omentum over the
Perforation and Securing of Sutures
Strangulation of the Omentum Repair
The original Graham patch describes using the previously Sutures tied too tightly may cause omental necrosis and
placed sutures to hold the omental tongue in place, as should be removed and replaced.
opposed to using them to formally close the perforation
itself (Figs. 154 to 156). However, care must be taken Prevention
not to strangulate the omentum when securing it in Sutures should be tied to prevent displacement of the
place. omentum without compromising vascular ow.

Consequence
Lack of Omentum
As noted previously, strangulation of the omentum can
lead to an increase in the postoperative leak rate and a Consequence
signicant increase in the morbidity and mortality asso- Some patients may not have sufcient omentum to
ciated with PPUD.28 allow for a Graham patch repair. However, other tissues
Grade 3 complication can be used in place of an omental patch, and the same
 15 GRAHAM PATCH REPAIR 163

Greater omental
pedicle
Duodenum

Omental plug inside of

perforated ulcer

Figure 156 Cross-sectional view of the omentum

secured across the perforation. The intent of the Stomach
omentum is to plug the defect, as opposed to closing
the defect primarily and buttressing the repair with the
omentum.

principles as that of the Graham patch can be employed Consequence

for fashioning a tissue repair
Grade 1 complication
Repair
The perforation can be suture-repaired primarily
without further reinforcement,29 though there are no
studies comparing differences in outcome in those
patients undergoing suture repair alone with those
undergoing Graham patch repair. There are also case
reports on the use of brin glue both to reinforce
suture closure of the duodenum and also as a sole
modality to seal a perforation.30,31 However, there are
no controlled studies evaluating the safety and efcacy
of brin glue as the only modality to seal a perforation,
and its use as the sole method of ulcer repair is not
advised. Finally, another option involves creating a
serosal patch by suturing the serosal surface of a loop
of jejunum over the perforation.
Prevention
This situation is not preventable because it is often due
to previous surgery or omentectomy. Previous abdom-
inal surgery should raise a surgeons index of suspicion,
and arrangements should be made for other types of
repairs should the patient be found to have insufcient
omentum.
Fascial and Skin Closure
Postoperative Drainage of the Dissection Bed
Routine drainage of the dissection bed postoperatively has
no role.32 Although there are no studies evaluating the
role of nasogastric decompression after duodenal ulcer
repair, most surgeons leave a nasogastric tube to continu-
ous suction for 24 to 48 hours after repair.
Postoperative drainage of the area of repair is rarely
required and has been reported to increase the risk for
infection.23,32
Grade 1 complication
Prevention
Drains should not be placed in the operative site.
Skin Closure
Consequence
Closure of skin after a delayed perforation can lead to
an increase in the wound infection rate. Wound infec-
tion has been shown to increase hospital stay, cost, and
the incidence of incisional hernia.33
Grade 1 complication
Repair
Wounds that become infected after closure should be
opened at the bedside and allowed to heal by secondary
intent.
Prevention
Although there are no studies evaluating the time at
which skin closure becomes prohibitive, skin should
not be closed if the perforation is greater than 12 hours
old. In such instances, delayed primary closure can be
performed in 2 to 3 days if the wound remains clean.
Other Complications
Treatment for Helicobacter pylori
Denitive acid-reducing operation may not be necessary
until H. pylori infection is addressed. It is well established
that the overwhelming majority of duodenal ulcers are
 164 SECTION III: GASTROINTESTINAL SURGERY
Box 152 Risk Factors for Reperforation in the
Early Postoperative Period
Admission heart rate >110 beats per minute
Systolic blood pressure <90 mm Hg
Hemoglobin <10 g/dl on admission
Albumin <2.5 g/dl
Lymphocyte count <1800 cells/mm3
Perforation size >5 mm
From Kumar K, Pai D, Srinivasan K, et al. Factors contributing to
releak after surgical closure of perforated duodenal ulcer by
Grahams patch. Trop Gastroenterol 2002;23:190192.
associated with H. pylori infection and that persistent
infection is predictive of ulcer recurrence or perfora-
tion.12,3441 Thus, patients should not be considered to
have failed medical therapy until an attempt is made to
eradicate this infection.12
Consequence
Failure to test and treat patients who are noted either
to have antibody to H. pylori or to carry the organism
itself increases the risk for ulcer recurrence.
Grade 1 complication
Repair
There are many treatment options for H. pylori. The
most recent recommendations include either an H2-
receptor antagonist or proton pump inhibitor for 2
to 4 weeks and clarithromycin with or without amoxi-
cillin for 2 weeks.42
Prevention
All patients should be tested and treated for H. pylori.
Given the near-ubiquitous presence of this infection in
patients with DUD, treatment should be started empir-
ically pending the results of testing.
Postoperative Reperforation and Leak
Box 152 lists the risk factors that predict reperforation
and leak in the immediate postoperative period.
Consequence
As noted previously, leakage from the area of repair in
the immediate postoperative period increases the peri-
operative mortality from 2% to 55%.28
Grade 25 complication depending on severity of
leak and septic response
Repair
There are no studies evaluating the best procedure in
such patients, but attempt at revision of Graham patch
alone is not recommended. Patients with reperforation
in the immediate postoperative period require more
denitive repair. Pitfalls related to complex duodenal
repairs are discussed elsewhere, but in addition to
control of the perforation, such patients should also
either undergo vagotomy or be placed on long-term
proton pump inhibitors.
Prevention
Patients with several of the previously noted risk factors
should not undergo Graham patch repair alone.23,28
Other options in such patients include vagotomy and
pyloroplasty or antrectomy, in acceptable operative
candidates.
REFERENCES
1. Hermansson M, Stael von Holstein C, Zilling T. Peptic
ulcer perforation before and after the introduction of H2-
receptor blockers and proton pump inhibitors. Scand J
Gastroenterol 1997;32:523529.
2. Tonus C, Weisenfeld E, Appel P, Nier H. Introduction
of proton pump inhibitorsconsequences for surgical
treatment of peptic ulcer. Hepatogastroenterology 2000;
47:285290.
3. Gustavsson S, Kelly KA, Melton LJ 3rd, Zinsmeister AR.
Trends in peptic ulcer surgery. A population-based study
in Rochester, Minnesota, 19561985. Gastroenterology
1988;94:688694.
4. Svanes C. Trends in perforated peptic ulcer: incidence,
etiology, treatment, and prognosis. World J Surg 2000;24:
277283.
5. Svanes C, Salvesen H, Stangeland L, et al. Perforated
peptic ulcer over 56 years. Time trends in patients and
disease characteristics. Gut 1993;34:16661671.
6. Boey J, Wong J, Ong GB. Bacteria and septic complica-
tions in patients with perforated duodenal ulcers. Am J
Surg 1982;143:635639.
7. Boey J, Wong J, Ong GB. A prospective study of
operative risk factors in perforated duodenal ulcers. Ann
Surg 1982;195:265269.
8. Makela JT, Kiviniemi H, Ohtonen P, Laitinen SO. Factors
that predict morbidity and mortality in patients with
perforated peptic ulcers. Eur J Surg 2002;168:446451.
9. Lee FY, Leung KL, Lai BS, et al. Predicting mortality and
morbidity of patients operated on for perforated peptic
ulcers. Arch Surg 2001;136:9094.
10. Lunevicius R, Morkevicius M. Management strategies,
early results, benets, and risk factors of laparoscopic
repair of perforated peptic ulcer. World J Surg 2005;8:8.
11. Svanes C, Lie RT, Svanes K, et al. Adverse effects of
delayed treatment for perforated peptic ulcer. Ann Surg
1994;220:168175.
12. Donovan AJ, Berne TV, Donovan JA. Perforated duode-
nal ulcer: an alternative therapeutic plan. Arch Surg 1998;
133:11661171.
13. Cellen-Jones C. A rapid method of treatment in perfo-
rated duodenal ulcer. Br Med J 1929;1:1076.
14. Graham R. The treatment of perforated duodenal ulcers.
Surg Gynecol Obstet 1937;64:235238.
15. Druart ML, Van Hee R, Etienne J, et al. Laparoscopic
repair of perforated duodenal ulcer. A prospective
multicenter clinical trial. Surg Endosc 1997;11:1017
1020.
16. Jamieson GG. Current status of indications for surgery in
peptic ulcer disease. World J Surg 2000;24:256258.
17. Khoursheed M, Fuad M, Safar H, et al. Laparoscopic
closure of perforated duodenal ulcer. Surg Endosc 2000;
14:5658.

18. Lau H. Laparoscopic repair of perforated peptic ulcer: a
meta-analysis. Surg Endosc 2004;18:10131021. Epub
2004;May 12.
19. Lunevicius R, Morkevicius M. Comparison of laparoscopic
versus open repair for perforated duodenal ulcers. Surg
Endosc 2005;5:5.
20. Robertson GS, Wemyss-Holden SA, Maddern GJ.
Laparoscopic repair of perforated peptic ulcers. The role
of laparoscopy in generalised peritonitis. Ann R Coll Surg
Engl 2000;82:610.
21. Berne T, Donovan A. Nonoperative treatment of perfo-
rated duodenal ulcer. Arch Surg 1989;124:830832.
22. Taylor H. Peptic ulcer perforation treated without
operation. Lancet 1946;2:441444.
23. Baker R. Operation for acute perforated duodenal ulcer.
In Nyhus L, Baker R, Fischer J (eds): Mastery of Surgery,
3rd ed. Boston: Little, Brown, 1997; pp 916920.
24. Fassiadis N, Roidl M, Hennig M, et al. Randomized
clinical trial of vertical or transverse laparotomy for
abdominal aortic aneurysm repair. Br J Surg 2005;92:
12081211.
25. Burger JW, vant Riet M, Jeekel J. Abdominal incisions:
techniques and postoperative complications. Scand J Surg
2002;91:315321.
26. Grantcharov TP, Rosenberg J. Vertical compared with
transverse incisions in abdominal surgery. Eur J Surg
2001;167:260267.
27. Gupta S, Kaushik R, Sharma R, Attri A. The management
of large perforations of duodenal ulcers. BMC Surg 2005;
5:15.
28. Kumar K, Pai D, Srinivasan K, et al. Factors contributing
to releak after surgical closure of perforated duodenal
ulcer by Grahams patch. Trop Gastroenterol 2002;23:
190192.
29. Koninger J, Bottinger P, Redecke J, Butters M. Laparo-
scopic repair of perforated gastroduodenal ulcer by
running suture. Langenbecks Arch Surg 2004;389:1116.
Epub 2003;Nov 15.
30. Mutter D, Evrard S, Keller P, et al. [Treatment of
perforated duodenal ulcer: the celioscopic approach]. Ann
Chir 1994;48:339344.
15 GRAHAM PATCH REPAIR 165
31. Benoit J, Champault GG, Lebhar E, Sezeur A. Sutureless
laparoscopic treatment of perforated duodenal ulcer. Br J
Surg 1993;80:1212.
32. Pai D, Sharma A, Kanungo R, et al. Role of abdominal
drains in perforated duodenal ulcer patients: a prospective
controlled study. Aust N Z J Surg 1999;69:210213.
33. Yahchouchy-Chouillard E, Aura T, Picone O, et al.
Incisional hernias. I. Related risk factors. Dig Surg 2003;
20:39.
34. Ng EK, Chung SC, Sung JJ, et al. High prevalence of
Helicobacter pylori infection in duodenal ulcer perforations
not caused by non-steroidal anti-inammatory drugs. Br J
Surg 1996;83:17791781.
35. Tokunaga Y, Hata K, Ryo J, et al. Density of Helicobacter
pylori infection in patients with peptic ulcer perforation. J
Am Coll Surg 1998;186:659663.
36. Kate V, Ananthakrishnan N, Badrinath S. Effect of
Helicobacter pylori eradication on the ulcer recurrence rate
after simple closure of perforated duodenal ulcer: retro-
spective and prospective randomized controlled studies. Br
J Surg 2001;88:10541058.
37. Kauffman GL Jr. Duodenal ulcer disease: treatment by
surgery, antibiotics, or both. Adv Surg 2000;34:121
135.
38. Kumar D, Sinha AN. Helicobacter pylori infection delays
ulcer healing in patients operated on for perforated
duodenal ulcer. Indian J Gastroenterol 2002;21:1922.
39. McFarlane G. Effect of Helicobacter pylori eradication on
the ulcer recurrence rate after simple closure of perforated
duodenal ulcer: retrospective and prospective randomized
controlled studies. Br J Surg 2002;89:493; author reply
494.
40. Mihmanli M, Isgor A, Kabukcuoglu F, et al. The effect of
H. pylori in perforation of duodenal ulcer. Hepatogastro-
enterology 1998;45:16101612.
41. Sebastian M, Chandran VP, Elashaal YI, Sim AJ. Helico-
bacter pylori infection in perforated peptic ulcer disease. Br
J Surg 1995;82:360362.
42. Helicobacter pylori and peptic ulcer disease. 2001. Avail-
able at http://www.cdc.gov/ulcer/keytocure.htm#
treatment (accessed May 11, 2008).
16
Vagotomy and Pyloroplasty
Tamica White, MD and Patrick G. Jackson, MD
INTRODUCTION
Pyloroplasty was rst performed by Heineke in 1886 for
a patient with an obstructing pyloric mass.1 Less than 1
year later, Mikulicz2 described a similar operation for the
treatment of a bleeding duodenal ulcer. Because of the
temporal relationship of these two reports, the technique
of opening the pylorus longitudinally and closing it trans-
versely is known as the Heineke-Mikulicz pyloroplasty.3
Over the next several decades, other methods of gastric
drainage were developed. In 1892, the Jaboulay pylorplasty,
a misnomer because it is actually a gastroduodenostmy,
was described for the treatment of an obstructing pyloric
mass.4,5 In 1902, Finney6 reported a method of pyloro-
plasty that also incorporated a gastroduodenostomy.3 It
was not until 1943 that Dragstedt sectioned the vagus
nerves just above the diaphragm to control hyperacidity
and popularized truncal vagotomy in conjunction with
pyloroplasty.7 Although described several decades ago, the
Heineke-Mikulicz pyloroplasty and Finney pyloroplasty
continue to be two of the most common techniques per-
formed by surgeons today for the treatment of peptic ulcer
disease.
Recurrence rates after truncal vagotomy are unaffected
by the type of pylorplasty performed.8,9 The Heineke-
Mikulicz pyloroplasty is recommended for routine cases
because of its ease and simplicity.10 However, in patients
with a very tight pyloric obstruction, this approach can be
difcult to perform.11 In cases in which the stomach lays
primarily in the longitudinal axis (i.e., is J-shaped), the
Finney pyloroplasty is the preferred technique.3,5 The
Finney pyloroplasty is also recommended in patients with
ulcers in the second portion of the duodenum or when
chronic inammation has displaced the pylorus and duo-
denum under the liver.10 In cases of severe scarring and
brosis of the pylorus, the Jaboulay gastroduodenostomy
is an alternative for gastric drainage.5
Vagotomy and pyloroplasty is considered a relatively
quick and simple operation with good postoperative
results.12 Long-term ulcer recurrence rates range from 5%
to 15%.3,7,8,10,13,14 Complications, although rare, do occur.13
Chan and coworkers15 reported a less than 1% mortality
rate. Skellenger and colleagues3 reported a major operative
complication rate of 5%, which included serious complica-
tions such as esophageal perforation, splenic rupture, and
anastomotic leak. Although vagotomy and pyloroplasty
has the potential to be mastered in a relatively short
period of time, its success is directly related to the train-
ing, experience, and attention to detail of the operating
surgeon.12,13
Vagotomy and pyloroplasty can be approached laparo-
scopically as well.16,17 The laparoscopic technique closely
duplicates the open approach and, therefore, is not
discussed here. Complications of general laparoscopy are
discussed in Section I, Chapter 8, Laparoscopic Surgery.
INDICATIONS
Obstructing gastric and/or duodenal ulcer
Bleeding gastric and/or duodenal ulcer
Perforated gastric and/or duodenal ulcer
Gastric replacement after esophagectomy
Pyloric stenosis (pyloroplasty only)
OPERATIVE STEPS
Vagotomy1820
Step 1 Mobilization of the left lobe of the liver (if
necessary)
Step 2 Incision of the peritoneal reection over the
distal esophagus
Step 3 Encirclement and placement of a Penrose drain
around the esophagus
Step 4 Exposure and resection of a segment of the ante-
rior vagus nerve
Step 5 Anterolateral traction on the esophagus to
expose the posterior vagus nerve
Step 6 Division and resection of a segment of the pos-
terior vagus nerve
Heineke-Mikulicz Pyloroplasty5,18,21
Step 1 Kocher maneuver
Step 2 Placement of stay sutures superiorly and inferi-
orly to the planned incision site
 168 SECTION III: GASTROINTESTINAL SURGERY

Step 3 Longitudinal incision anteriorly through all Consequence

layers of the pylorus extending onto the stomach Bleeding.
and duodenum Grade 2/3 complication
Step 4 Transverse closure of the incision
Step 5 Placement of an omental patch over the pyloro- Repair
plasty (optional) The vein can be ligated with impunity once
identied.
Finney Pyloroplasty5,18,21
Prevention
Step 1 Kocher maneuver The phrenic vein should be anticipated during the dis-
Step 2 Placement of stay sutures (at the superior section to avoid transecting it unexpectedly. In those
margin of the pyloric ring and 10 cm proximal patients with a particularly turgid or brotic left lobe,
and distal to the pylorus on the stomach and mobilization is futile because the lobe will be extremely
duodenum) difcult to fold.22
Step 3 Interrupted row of posterior seromuscular
sutures through the apposing walls of the Encircling the Esophagus and Identication of
stomach and duodenum the Vagus Nerves
Step 4 U-shaped incision into the lumen of the stomach
Esophageal Perforation
extending to the duodenum transecting the
pylorus Consequence
Step 5 Running closure of the posterior and anterior Intra-abdominal leak with peritonitis. Esophageal per-
inner layers between the stomach and the foration during vagotomy is a rare complication with
duodenum an incidence of less than 1%2224 (Fig. 161). However,
Step 6 Interrupted row of anterior seromuscular the morbidity of this complication is high, particularly
sutures if it goes unrecognized during the original procedure.25
Step 7 Placement of an omental patch over the pyloro- Skellenger and colleagues3 reported that esophageal
plasty (optional) perforation during vagotomy is usually the result of
blind nger dissection of the esophagus. Factors con-
tributing to esophageal perforation include the obese,
patients with friable inamed tissue, portal hyperten-
Jaboulay Pyloroplasty5,21
sion, or previous surgery in that region.22
Step 1 Kocher maneuver Grade 3/4/5 complication
Step 2 Placement of traction sutures to approximate the
duodenal and gastric walls Repair
Step 3 Interrupted row of seromuscular sutures Esophageal perforation identied intraoperatively
through the apposing walls of the stomach and should be repaired primarily in layers. Postoperative
duodenum esophageal leak can be managed with nasogastric tube
Step 4 Incisions into the lumen of the stomach and decompression and antibiotics when appropriate.
duodenum leaving the pylorus intact Larger postoperative leaks with evidence of peritonitis
Step 5 Running closure of posterior and anterior and hemodynamic instability require reoperation.
inner layers between the stomach and the
duodenum
Step 6 Interrupted row of anterior seromuscular
sutures Diaphragm
Step 7 Placement of an omental patch over the pyloro-
plasty (optional) Finger passed behind
esophagus

Hiatus
OPERATIVE PROCEDURE

Mobilization of the Left Lobe of the Liver

Injury to the Phrenic Vein
In some cases, the left lobe of the liver must be taken
down in order to provide exposure to the gastroesopha-
geal junction. Care must be taken not to enter the rather
large phrenic vein located within the diaphragm in this
region.21 Figure 161 Encircling esophagus at hiatus.

Prevention
When encircling the esophagus, the surgeon should
stay wide on the esophagus in order to prevent
inadvertent entry into the lumen.10 In addition, care
should be taken to encircle the esophagus above the
diaphragm to be certain that the posterior vagus is
included in the maneuver.19 The posterior vagus nerve
can be found by palpation superiorly on the esophagus
to localize the vagus nerve before it is separated from
the esophageal tissue. If the nerve is still not found,
inspection in the tissue on the right crus as well as the
para-aortic region can often expose the posterior vagus
nerve.19 Unwarranted dissection within the posterior
muscular wall of the esophagus in search of vagal
strands increases the chance of perforation.
Splenic Injury
Consequence
Bleeding.
Grade 2/3/4 complication
Repair
Wirthlin and associates22 reported a 2.7% incidence of
splenic injury with vagotomy. A tear in the splenic
capsule can usually be controlled with electrocautery or
Gelfoam. If the tear is more extensive and bleeding
cannot be controlled, splenectomy may be required. In
cases in which an uncontrolled short gastric artery is
the cause of hemorrhage, care must be taken to gently
reect the stomach toward the left lobe of the liver in
order to allow for optimal visualization during ligation
of the vessels.
Prevention
Meticulous attention to the splenic tip is required when
dissecting in the region of the gastroesophageal junc-
tion. Minimizing blind or unwarranted dissection will
aid in avoiding inadvertent injury to the spleen.
Injury to the Thoracic Duct
Consequence
Chylous ascites following vagotomy is very rare. Only
a handful of case reports are found in the literature.26
This complication is believed to result from injury to
an aberrant lymphatic trunk at the lower portion of the
esophagus.
Grade 2/3 complication
Repair
Cox and colleagues27 reported a case of spontaneous
resolution of chylous ascties after treatment with only
simple drainage. Nonoperative treatment with drainage
and total parenteral nutrition followed by a low-fat diet
can be attempted rst. Patients who do not improve
within 6 weeks may require reoperation with ligation
of the injured lymphatic channel.28,29
16 VAGOTOMY AND PYLOROPLASTY 169
Prevention
The cisterna chyli, when present, lies to the right side
of the abdominal aorta, in front of the rst two lumbar
vertebrae, and is usually well covered by the right crus.
Frequently, a true cisterna is not present and the tho-
racic duct is formed directly by the collecting lymphatic
vessels.26 The lymphatics can be as small as 2 to 3 mm
in diameter, making them difcult to identify. There-
fore, during dissection, any neighboring structures sus-
picious of being lymphatics must be properly isolated
and ligated.
Dysphagia
Consequence
Prolonged inability and/or difculty with solid foods.
Grade 2/3 complication
Repair
Esophageal dilation is usually successful in treating
most patients.3 If unsuccessful, reoperation with esoph-
ageal myotomy may be required.
Prevention
The overall incidence of postvagotomy dysphagia
ranges from 1% to 3%.22,24,30 The onset may be early or
months after the operation. Periesophageal brosis and
denervation of the lower esophagus have been sug-
gested as factors contributing to dysphagia.30 Complete
knowledge of the anatomy in the region of the gastro-
esophageal junction is required in order to avoid
unnecessary dissection of the lower esophagus. In addi-
tion, complete stripping of the lower esophagus during
isolation of the vagus nerves should be avoided to
prevent denervation and devascularization.
Division and Resection of the Vagus Nerves
Incomplete Vagotomy
Consequence
Recurrent ulceration. Not all patients with incomplete
vagotomy develop recurrent ulcers. However, it is
generally accepted that ulcer recurrence after vagotomy
is due to incomplete nerve section (Fig. 162).31 Soybel
and coworkers18 reported that approximately two thirds
of patients with duodenal or pyloric channel ulcer
recurrence after initial vagotomy have evidence of intact
vagal innervation.
The majority of patients with recurrent ulcers present
with intractable pain or bleeding.
Grade 2/3 complication
Repair
Some recurrences will be amenable to medical treat-
ment. However, patients who are refractory to medical
management will require reoperation. Skellenger and
colleagues3 reported that revagotomy alone for the
treatment of recurrent ulcers is indicated only for those
patients with elevated basal acid secretion or a clear-cut
 170 SECTION III: GASTROINTESTINAL SURGERY

Longitudinal line of incision

through anterior wall of pylorus

Figure 162 Division of posterior vagus.

Figure 164 Location of Heineke-Mikulicz pyloroplasty.

separated and ligated. However, failure to identify each

cord will result in incomplete vagotomy. When identi-
fying the posterior vagus nerve, care must be taken to
make sure that the criminal nerve of Grassi is distal
to the area of proposed resection. Although this nerve
is usually found wrapping around the cardiac notch
from its origin at the posterior vagal trunk, it can occa-
sionally ramify more proximally above the gastroesoph-
ageal junction.18 After each nerve resection, a specimen
of the vagus should always be sent to the pathologist
for histologic conrmation.

Incision through the Pylorus and/or

Stomach/Duodenum
Figure 163 Division of anterior vagus.
Failure of Adequate Drainage
vagal response to insulin. Kennedy and associates 32
reported a 16% re-recurrence rate after revagotomy
alone compared with a 1.4% rate after revagotomy and
antrectomy. The majority of patients with ulcer recur-
rence after truncal vagotomy and pyloroplasty are best
treated with revagotomy and antrectomy.
Prevention
Although incomplete vagotomy is more common with
other types of vagotomies (highly selective, parietal
cell), careful attention is imperative when dividing the
vagus nerves during truncal vagotomy to avoid leaving
small bers behind. During dissection of the anterior
vagus nerve (approximately 24 cm above the gastro-
esophageal junction), the surgeon must be aware that
it is not uncommon for vagal bers to be distributed
among two or three smaller cords at this level (Fig.
163). These cords are usually quite visible and easily
Consequence
Level 1 evidence shows that persistent vomiting, epi-
gastric fullness, dyspepsia, or heartburn occurs in
approximately 10% of patents after vagotomy and pylo-
roplasty.3335 Many of these symptoms resolve after the
immediate postoperative period. Prolonged symptoms
are usually due to an inadequate pyloroplasty that does
not allow sufcient drainage of gastric contents through
the pyloroplasty and into the duodenum3 (Fig. 164).
Grade 1/2/3 complication
Repair
Patients with mild symptoms can be treated medically.
Gastric outlet obstruction with severe, intractable
symptoms will require reoperation with construction of
a new drainage procedure. Patients with both reux
esophagitis and painful alkaline reux gastritis may
require a Roux-en-Y diversion procedure.3
 16 VAGOTOMY AND PYLOROPLASTY 171

First (back) row Traction suture

of serosal
sutures in place
Line if incision
through wall
Line of incision of stomach
through wall
of duodenum

Posterior through
and through suture

Figure 167 Inner layer of Finney pyloroplasty.

Figure 165 Creation of back row of Finney pyloroplasty.

Figure 168 Weinberg modication of closure for Heineke-

Mikulicz pyloroplasty.

Closure of the Pyloroplasty

Figure 166 Closure of anterior wall of Finney pyloroplasty.
Prevention
Except for cases of pyloric stenosis, pyloroplasty is per-
formed to overcome the gastric stasis caused by vagot-
omy. During pyloroplasty, if the incision through the
pylorus is not long enough, drainage of the stomach
into the duodenum will be insufcient (see Fig. 164).
A minimal 5-cm incision is recommended for a Finney
or Jaboulay pyloroplasty (Figs. 165 to 167). During
the Heineke-Mikulicz pyloroplasty, the pylorus should
be palpated to ensure complete transaction of the
muscle with clear extension onto the stomach and duo-
denum. In addition, any dog-ears at the ends of the
incision after closure should not be infolded because
this can narrow the lumen.
Anastomotic Leak
Consequence
Peritonitis, abscess.
Grade 3/4/5 complication
Repair
Drainage and/or reoperation with repair or revision of
the anastomosis. Any patient having unexplained fever
or inappropriate abdominal pain postoperatively should
be evaluated for possible anastomotic leak (Fig. 168).
Depending on the severity of the leak, surrounding
inammation, and stability of the patient, either primary
repair or diversion can be performed.
Prevention
With respect to the Heineke-Mikulicz pyloroplasty,
there is no evidence in the literature to suggest that a
two-layer closure is superior to a single-layer closure
 172 SECTION III: GASTROINTESTINAL SURGERY
(Weinberg modication) in preventing an anastomotic
leak. In fact, many advocate this modication because
it is believed to result in a larger opening with improved
gastric emptying.5 Two-layer closures are indicated for
the Finney and Jaboulay pyloroplasties. When closing
the defect, full-thickness sutures must be placed through
all layers of the bowel to ensure a proper anastomosis.
Although level 1 evidence is lacking from the literature,
placing a tongue of vascularized omentum over the
anastomosis to buttress the pyloroplasty is advocated.
Other Complications
Inadequate/Incomplete Kocher Maneuver
Grade 2/3 complication
It is essential to fully mobilize the duodenum by perform-
ing a complete Kocher maneuver. Little is reported in the
literature about this complication. However, failure of
adequate mobilization of the duodenum results in undue
tension on the anastomosis of the pyloroplasty. Moreover,
proper apposition of the stomach and duodenum when
performing a Finney or Jaboulay pyloroplasty is nearly
impossible without full mobilization of the duodenum.
Pneumothorax
Grade 2 complication
Wirthlin and associates22 reported 1 case of pneumothorax
from their series over 1000 vagotomies. The patient was
treated conservatively without a chest tube and had no
long-term sequelae. Although rare, this complication must
be considered particularly when a patient presents with
respiratory difculties postoperatively. Prevention of a
pneumothorax is best accomplished by avoiding unneces-
sary proximal esophageal dissection into the chest. If the
pleura is visualized, care should be taken to reect it later-
ally without entering the pleural space.
Aortic Injury
Grade 5 complication
Aortic injury during the esophageal dissection portion of
the vagotomy is extremely rare. Inexperience with dissect-
ing around the gastroesophageal junction is usually the
cause of injury. It is imperative that the surgeon under-
stands the anatomic relationship between the esophagus,
the crura, and the aorta. The aorta lies just behind the
esophagus and can be hidden by the left crus. When dis-
secting around the esophagus, care must be taken not to
injure the aorta inadvertently. Immediate primary repair
is required.
REFERENCES
1. Fronmuller F. Operation der Pylorusstenose [Erlangen
dissertation]. Furth, Schroder, 1886; pp 119.
2. Mikulicz J. Zur operativen behandlung des stenosirenden
magengeschwures. Arch Klin Chir 1888;37:7990.
3. Skellenger ME, Jordan PH. Complications of vagotomy
and pyloroplasty. Surg Clin North Am 1983;63:1167
1180.
4. Jaboulay M. La gastro-enterostomie, la jejuno-
duodenostomie, la resection du pylore. Arch Prov Chir
1892;1:1112.
5. Sawyers JL, Richards WO. Selective vagotomy and
pyloroplasty. In Baker RJ, Fisher JE (eds): Mastery of
Surgery, 4th ed. Philadelphia: Lippincott Williams &
Wilkins, 2001; pp 933941.
6. Finney JMT. A new method of pyloroplasty. Johns
Hopkins Bull 1902;13:155161.
7. Woodward ER. The history of vagotomy. Am J Surg
1987;153:917.
8. Pemberton JH, VanHeerden JA. Vagotomy and pyloro-
plasty in the treatment of duodenal ulcer: long-term
results. Mayo Clin Proc 1980;55:1018.
9. Stempien SJ, Dagradi AE, Lee ER. Status of duodenal
ulcer patients ten years or more after vagotomy-
pyloroplasty. Am J Gastroenterol 1971;56:99108.
10. Thompson BW, Read RC. Long-term randomized
prospective comparison of Finney and Heineke-Mikulicz
pyloroplasty in patients having vagotomy for peptic
ulceration. Am J Surg 1975;129:7881.
11. Samsi AB, Pandya AP, Kulkarni VR, et al. Finneys
pyloroplasty in chronic pyloric obstruction. J Postgrad
Med 1980;26:112115.
12. Robles R, Parrilla P, Lujan JA, et al. Long-term follow-up
of bilateral truncal vagotomy and pyloroplasty for perfo-
rated duodenal ulcer. Br J Surg 1995;82:665.
13. Stabile BE. Current surgical management of duodenal
ulcers. Surg Clin North Am 1992;72:335355.
14. Welch CE, Rodkey GV, vonRyll Gryska P. A thousand
operations for ulcer disease. Ann Surg 1986;204:454
467.
15. Chan VM, Reznick RK, ORourke K, et al. Meta-analysis
of highly selective vagotomy versus truncal vagotomy and
pyloroplasty in the treatment of uncomplicated duodenal
ulcer. Can J Surg 1994;37:457464.
16. Prietratta JJ, Schultz LS, Graber JN. Experimental
transperitoneal laparoscopic pyloroplasty. Surg Laparosc
Endos 1992;2:104.
17. Snyders D. Laparoscopic pyloroplasty for duodenal ulcer.
Br J Surg 1993;80:127.
18. Soybel DI, Zinner MJ. Stomach and duodenum: operative
procedures. In Zimmer MJ, Schwartz SI, Ellis H (eds):
Mangoits Abdominal Operations. New York: Appleton
and Lange, 1997; pp 10791097.
19. Pappas TN. Truncal vagotomy. In Sabiston DC (ed):
Atlas of General Surgery. Philadelphia: WB Saunders,
1994; pp 328332.
20. Roberts JP, Debas HT. A simplied technique for rapid
truncal vagotomy. Surg Gynecol Obstet 1989;168:539
541.
21. Meyers WC: Heineke-Mukulicz pyloroplasty. In Sabiston
DC (ed): Atlas of General Surgery. Philadelphia: WB
Saunders, 1994; pp 251253.
22. Wirthlin LS, Malt RA. Accidents of vagotomy. Surg
Gynecol Obstet 1972;135:913916.
23. Simmons RL, Back VR, Harvey HD, Herter FP. Techni-
cal complications of trans-abdominal vagotomy. Arch Surg
1966;92:922.

24. Postlethwait RN, Kim SK, Dillon ML. Esophageal
complications of vagotomy. Surg Gynecol Obstet
1969;128:481488.
25. Hauser JB, Lucas RJ. Esophageal perforation during
vagotomy. Arch Surg 1970;101:466.
26. Al-Mousawi M, Abu-Nema T. Chylous ascites: a rare
complication of vagotomy. Eur J Surg 1991;157:149
150.
27. Cox WD, Schmitz RT, Gillesby WJ. Unusual complica-
tions of vagotomy and pyloroplasty. Am J Surg
1966;32:259.
28. Clain A. Chylous ascites following vagotomy. Br J Surg
1991;58:312.
29. Hocking MA, Barth CE. Chylous ascites, a complication
of vagotomy. J R Coll Surg Edinb 1978;23:232.
30. Anderson HA, Schlegel JF, Olsen AM. Post vagotomy
dysphagia. Gastrointest Endosc 1966;12:13.
16 VAGOTOMY AND PYLOROPLASTY 173
31. Johnson AG, Baxter HK. Where is your vagotomy
incomplete? Observations on operative technique. Br J
Surg 1977;64:583586.
32. Kennedy T, Roger-Green WE. Stomal and recurrent
ulceration: medical or surgical management. Am J Surg
1980;139:1821.
33. Kennedy T, Connell AM, Love AGH. Selective or truncal
vagotomy? Five year results of a double blind randomized
controlled trial. Br J Surg 1973;60:944948.
34. Robb JV, Banks S. Marks IN, et al. A comparison between
selective vagotomy and truncal vagotomy with drainage
in duodenal ulceration. South Afr Med J 1973;47:1391
1396.
35. Hojlund B, Madsen P. The clinical results of selective
vagotomy and pyloroplasty 69 years later. Dan Med Bull
1980;27:164167.
17
Laparoscopic Nissen Fundoplication
Stephen R. T. Evans, MD and
Elizabeth A. David, MD

INTRODUCTION Progressive regurgitant symptoms

Extraesophageal manifestations
Since the early 1990s, laparoscopic Nissen fundoplication Proton pump inhibitor failures
(LNF) has come to replace open fundoplication as the sur-
gical gold standard and procedure of choice for gastro-
esophageal reux disease (GERD). Some data suggest that OPERATIVE STEPS 2
LNF is associated with more life-threatening complica-
tions than open fundoplication, but when the learning Step 1 Positioning and trocar placement
curve is taken into account, in experienced hands, the Step 2 Liver retraction
laparoscopic approach has proved to have signicant advan- Step 3 Division of the hepatogastric ligament
tages over the open procedure.1 The less life-threatening Step 4 Dissection of the crura and phrenoesophageal
complications of splenectomy and pneumonia seen in ligament
open Nissen fundoplication are rare in LNF, but these are Step 5 Lengthening of the abdominal esophagus (if
replaced with more potentially serious injuries. Despite necessary)
articles specically focused on error prevention in LNF, Step 6 Stomach mobilization and ligation of short
life-threatening and lethal complications still occur.2 gastric vessels
First reported in the literature in 1991, LNF is a complex Step 7 Retroesophageal dissection at the GE junction
advanced laparoscopic procedure that has excellent out- Step 8 Bougie and nasogastric tube placement
comes when performed by experienced surgeons. However, Step 9 Closure of the esophageal hiatus
even in the best of hands, serious complications can result.3 Step 10 Retroesophageal wrap
Rantanen and coworkers1 reported a prevalence of 1.3% Step 11 Suture placement for the wrap
for life-threatening complications and 1.2% for non Step 12 Fixation of the wrap to the right crus
life-threatening complications. Predictors of success for Step 13 Trocar removal
this operation have been published elsewhere, but overall
patient satisfaction has been extremely high.4
OPERATIVE PROCEDURE
Certain patient populations, specically morbidly obese
patients with body mass indexes (BMIs) greater than 30,
Trocar Insertion
may be at increased risk for complications with LNF.5
Presumably, in the morbidly obese patient, visibility can Trocar Insertion Injuries
be limited in the upper abdomen, creating a more difcult Life-threatening and less serious complications can occur
gastroesophageal (GE) junction dissection and more dif- with trocar insertion. A standard ve-trocar technique is
culty with takedown of the short gastric and other vessels, used: a 5-mm port in the right midabdomen, a 10-mm
leading to a higher complication rate both intraoperatively port subxiphoid, a 5-mm port to the left of the xiphoid,
and postoperatively. However, good data indicate no a 10-mm port in the left midabdomen, and a Hasson port
increased risk of complications in the elderly or the pedi- supraumbilically. Complications of trocar insertion are
atric population.68 The only other population at increased discussed in Section I, Chapter 7, Laparoscopic Surgery.
risk for complications are those patients with prior exten-
sive upper abdominal surgery.
Division of the Hepatogastric Ligament
INDICATIONS Injury to an Aberrant Left Hepatic Artery
As the hepatogastric ligament is dissected to visualize the
Young patient population well controlled on proton right crus and right phrenoesophageal ligament, approxi-
pump inhibitors mately 10% of patients will have an aberrant left hepatic
 176 SECTION III: GASTROINTESTINAL SURGERY

artery branching off the left gastric artery, making this

vessel prone to injury if it is not visualized.9
Consequence
Excessive bleeding with uncontrolled transection of the
aberrant left hepatic artery and/or potential left hepatic
lobe compromise with ischemia. If the patient has cir-
rhosis and/or signicant hepatic compromise, ligation
of this aberrant left hepatic artery (36% are accessory,
64% are replaced) may lead to clinically signicant
hepatic ischemia.
Grade 24 complication
Repair
Ligation may be carried out if there is no obvious
hepatic compromise. However, end-to-end anastomo-
A
sis may be necessary in patients with limited hepatic
reserve.
Prevention
Visualization of the aberrant vessel through what is
usually a transparent hepatogastric ligament is critical,
especially in light of the frequency of this anatomic
vascular anomaly (Fig. 171A). Frequently, the vessel
can be reected out of the operating eld while still
maintaining full visualization and allowing takedown of
the right phrenoesophageal ligament and dissection of
the GE junction. A small-caliber aberrant left hepatic
artery would strongly suggest this to be an accessory
vessel; it could be ligated if necessary to obtain ade-
quate access to the GE junction and phrenoesophageal
ligament. However, a larger-caliber vessel (e.g., >3
4 mm in diameter) should be reected out of the oper- B
ating eld and spared for the reasons mentioned Figure 171 A, The hepatogastric ligament is shown above the
previously (see Fig. 171B). caudate lobe (small arrow) with evidence of an aberrant left hepatic
artery (large arrow) and the left lateral segment reected anteriorly
(curved arrow). B, Dissection of the aberrant left hepatic artery out
Dissection of the Crura and Phrenoesophageal of the operating eld with retraction. The size of this vessel strongly
Ligament with Lengthening of the Abdominal suggests this is a replacement vessel, which would be spared and
Esophagus (GE Junction Dissection) not ligated merely for convenience of the dissection.

Vagus Nerve Injury

Consequence
Postvagotomy diarrhea (10%15%) and delayed gastric
emptying.
Grade 1 complication
Prevention
The operating surgeon must visualize both anterior and
posterior vagal trunks during the dissection of the GE
junction and takedown of the right, left, and anterior
phrenoesophageal ligaments (Fig. 172A). Some sur-
geons actually insert the wrap inside of the vagal nerve
trunks, making sure that both trunks have been clearly
delineated. The anterior nerve can be tethered up close
to the phrenoesophageal ligament and must be reected
back onto the esophagus anteriorly. The posterior
trunk is most commonly injured when the retroesoph-
ageal window is created. Care must be taken to again
reect the nerve anteriorly onto the esophagus to
prevent injury (see Fig. 172).
Esophageal Injury
Consequence
Intra-abdominal leak with peritonitis. The reported
incidence for this complication is roughly 1%; however,
it carries a mortality rate of greater than 20%, making
it one of the most important and lethal complications
of LNF.10 This complication has been well described in
the literature. When looking at specic mechanisms of
esophageal perforations, Schauer and associates10 iden-
tied the majority of injuries occurring from improper
retroesophageal dissection. Obesity and large hiatal
hernias were found to contribute to esophageal injury
secondary to excessive fatty tissue in the periesophageal
 17 LAPAROSCOPIC NISSEN FUNDOPLICATION
A proceed from right to left, anterior to the left crus of
B
Figure 172 A, The right and left crura are outlined (small
arrows) and the anterior vagus is easily visualized in its midposition
on the esophagus (large arrow). At this point in the dissection, with
mobilization of the right and left phrenoesophageal ligaments com-
pleted, the dissection anteriorly should extend well above the
anterior vagal trunk, pushing the vagus down onto the esophagus
to minimize risk of injury. B, The posterior vagal trunk is shown
by the arrow. The esophagus is being reected anteriorly. The
retroesophageal window is created, and at this point in the dissec-
tion, the posterior vagal trunk should be reected anteriorly with
the esophagus to minimize the risk of injury.
region that obscures tissue planes and complicates dis-
section. As with other complications of LNF, experi-
ence of the surgeon is a risk factor for this complication.
Schauer and associates10 reported that 10 of 17 esoph-
ageal perforations identied collectively from several
institutions occurred during the rst 10 LNFs per-
formed by each surgeon.
Grade 25 complication
Repair
The esophageal perforations can be closed laparoscop-
ically if the surgeon has an extensive experience and
comfort level with this. Otherwise, conversion to an
open procedure should be performed with a layered
closure. Proper postoperative management includes
177
appropriate positioning of a nasogastric tube, antibiot-
ics, and a swallow study that conrms no on-going leak
(prior to removal of the nasogastric tube).
Prevention
Retraction of the esophagus should be carried out only
with Penrose drains around the GE junction (Fig. 17
3A) or with retraction bluntly such as with the endo-
scopic Babcock retractor (see Fig. 173B). Grasping of
the esophagus or junction with the retractors as previ-
ously discussed will lead to a high incidence of linear
tears within the esophagus and catastrophic outcomes
(see Fig. 173C). Dissection should be performed away
from the esophagus to minimize the risk of injury and
devascularization. Retroesophageal dissection should
the diaphragmdissection too superior can lead to
pneumothorax secondary to pleural penetration, too
anterior can lead to esophageal perforation, and too
inferior may lead to gastric perforation. If a tear is
suspected (and commonly, these may be linear through
the longitudinal muscle and difcult to visualize), insuf-
ation with the nasogastric tube proximal to this area,
with distal occlusion using a noncrushing bowel clamp
and saline over the esophagus and stomach inspecting
for leak, has been shown in animal studies to be a useful
modality. This may hasten diagnosis of occult injuries,
which may decrease the morbidity of perforation inju-
ries in the future.11
Pneumothorax, Pneumomediastinum,
and Pneumopericardium
Consequence
Hypercarbia and increased airway pressures. Murdock
and colleagues12 studied over 900 laparoscopic cases to
identify which patients were at risk for developing
hypercarbia, subcutaneous emphysema, pneumotho-
rax, and pneumomediastinum. They concluded that
longer operative times (>200 min), higher maximum
measured end-tidal CO2, a greater number of surgical
ports, older patient age, and Nissen fundoplications
all predisposed to hypercarbia-related complications
during laparoscopy. Of note, the relation between LNF
and hypercarbia was attributed to the length of the
procedure (mean 227 min), which would increase the
risk of pneumothorax/pneumomediastinum by 20
times based on procedure length alone.12
Grade 1/2 complication
Repair
The vast majority of patients with CO2 pneumothora-
ces will resolve spontaneously on their own and do not
require chest tubes. Extensive dissections into the chest
for mobilization of the esophagus commonly leads to
subcutaneous emphysema and hypercarbia. Communi-
cation between the surgeon and the anesthesiologist
will allow for the ventilators to be set at higher rates
 178 SECTION III: GASTROINTESTINAL SURGERY

A B

Figure 173 A, The Penrose drain is placed around the gastro-

esophageal (GE) junction for retraction in an atraumatic fashion. Both
right and left crura are shown by arrows. This atraumatic retraction
minimizes the risk of gastric or esophageal tears or perforations.
B, Other options for retraction include simple reection of the GE
junction and esophagus in the appropriate vector necessary. Here,
the blunt side of the endoscopic Babcock reects the esophagus
anteriorly, exposing the hiatus and the right and left crura (arrows).
C, Grasping the esophagus or the GE junction in this fashion will
clearly lead to a high incidence of linear tears in the esophagus and
C should be avoided at all cost. Of note is the aorta behind the left
crus in this view (arrow).

with higher minute ventilations to reduce end-tidal

CO2 such that it can be maintained at a safe rate.
Positive end-expiratory pressure (PEEP) has been used
to correct the respiratory changes related to the effects
of CO2 retention during extensive laparoscopic surger-
ies with a high rate of success. By decreasing the pres-
sure gradient between the abdominal and the pleural
cavities during both inspiration and expiration, PEEP
therapy provides a means of reinating a collapsed lung
without invasive intervention.13
Prevention
The close proximity of the right and left pleura (espe-
cially the left pleura) in the mediastinal dissection must
be understood during mobilization of the esophagus
to achieve abdominal esophageal lengthening. The dis-
section should push the pleura away from the operative
eld (i.e., in the lateral plane of the thoracic dissection). Figure 174 The edge of the right pleura (arrow) is visualized in
Commonly, in an attempt for the surgeon to stay off the intrathoracic dissection. Care should be taken to reect the
the esophagus, the dissection extends out too far later- pleura out laterally on the right and left sides and not to dissect
ally into the chest and the pleural space (Fig. 174). straight through it; otherwise, the CO2 pneumothorax will occur.
 17 LAPAROSCOPIC NISSEN FUNDOPLICATION 179

Ligation of the Short Gastric Vessels
Splenic Injury and/or Bleeding
Consequence
Bleeding.
Grade 2/3 complication
Repair
Ligation of the short gastric vessels requires excellent
visualization when moving superiorly and posteriorly
into the upper abdomen. This requires reection of the
stomach toward the left lateral segment of the liver.
The harmonic scalpel is most commonly used at this
step. Sponges and Gelfoam may be used to control
bleeding and aid in visualization. In situations in which
hemostatic control is not excellent, conversion to an
open procedure may be required to achieve hemostasis,
especially if there is a tear on the splenic capsule. This
requires meticulous visualization with suctioning, and
frequently, an additional trocar must be placed to allow
an additional set of hands to expose the vessels or the
site of the splenic tip.
Prevention
An extensive gastric mobilization of the entire fundus
and cardia allows the stomach to be reected so that
visualization of the posterior wall is facilitated. This
allows an easier dissection down to the short gastric
vessels with the spleen reected off to the side. When
a harmonic scalpel is used to ligate the short gastric
vessels, the common mistakes are that the scalpel is
not held in the neutral position and that the vessels
separate prematurely without complete closure (Fig.
175).

A B

C D

Figure 175 A, The harmonic scalpel used to mobilize the greater curve of the stomach and the short gastrics is shown here in the
correct neutral position allowing tissue with retraction medially and laterally to release upon completion of sealing of the tissue. B, The
harmonic scalpel is being retracted anteriorly, which can lead to premature release of the tissues and bleeding, especially in difcult areas,
as the short gastrics are taken in closer proximity to the spleen. C, The second error in technique that can lead to bleeding from the
harmonic scalpel is incomplete control of the vessel as shown here in which only partial approximation of the vessels is obtained, again
leading to potential uncontrolled bleeding. D, The stomach is reected anteriorly to allow exposure posteriorly, which minimizes the risk
of injury along the greater curve of the stomach and also allows better visualization of the short gastric and the relationship between the
spleen and the stomach as the dissection moves proximally.
 180 SECTION III: GASTROINTESTINAL SURGERY
Figure 176 The harmonic scalpel is in too close proximity to
the stomach. This can lead to thermal injury and delayed gastric
perforation with subsequent peritonitis and sepsis. The harmonic
scalpel in this setting should be moved to the right, allowing an
adequate distance of at least 2 to 3 mm to minimize thermal injury
to the stomach. Even as one moves in closer proximity to the
stomach and the spleen, the harmonic scalpel should err on the
side of the spleen, not on the side of the stomach.
Gastric Injury, Acute or Delayed (Thermal)
Consequence
Perforation with peritonitis. Extensive retraction of the
stomach for better visualization can lead to serosal and
full-thickness tears of the stomach. In addition, use of
the harmonic scalpel in close proximity to the stomach
can contribute to thermal injuries, leading to delayed
perforations and, subsequently, to delayed peritonitis
with potentially serious or life-threatening conse-
quences (Fig. 176).
Grade 25 complication
Repair
Primary closure of these esophageal injuries can be
carried out without difculty both laparoscopically
(depending on the surgeons comfort level) and by
conversion to an open procedure. The more challeng-
ing and difcult issue is the problem of thermal injury
with delayed perforation. In the setting of what appears
to be a thermal injury, which may or may not be full
thickness, excising or oversewing this area may be
useful. The use of prolonged nasogastric suctioning,
administering perioperative antibiotics, and using
omentum to buttress this area have also proved useful.
Testing the stomach for occult perforations has proved
to be useful, as previously outlined, with insufation
and saline wash.11
Prevention
When the short gastric vessels are being ligated, the
harmonic scalpel needs to be held in the neutral posi-
tion. Especially when the vessels are extremely short,
Figure 177 The most oppy portion of the cardia utilizing the
short gastrics as the landmark has been brought through the retro-
esophageal window, as shown by the arrow. There is no retraction
on this. The left portion of the cardia now can easily be brought
up in proximity for a tension-free oppy approximation.
the harmonic scalpel must be moved on the side of the
spleen, not on the side of the stomach, to minimize the
risk of full-thickness thermal injuries to the stomach.
Gastric tears can be minimized by appropriate retrac-
tion of the stomach with blunted instruments. Penrose
drain retraction of the GE junction is used so that tears
with retraction are minimized.
Gas Bloat Syndrome
Consequence
The reported incidence of poor quality of life with
inability to burp or belch is approximately 1% to 7%
postoperatively.14
Grade 1/2 complication
Prevention
The inability to burp or belch after LNF is believed by
many surgeons to be due to a wrap under tension
because all the short gastric vessels were not ligated.
Level-one evidence suggests that there is no relation-
ship between the takedown of the short gastric vessels
and the incidence of gas bloat syndrome.15 However,
this author and several other surgeons believe that
extensive mobilization does lead to a more oppy wrap
and, considering the very low incidence, may in fact
require an extremely large randomized study to prove
otherwise16 (Fig. 177).
Bougie and Nasogastric Tube Insertion
Esophageal and Gastric Perforation
Consequence
Viscus leak with peritonitis (Fig. 178).
Grade 25 complication
 17 LAPAROSCOPIC NISSEN FUNDOPLICATION
Figure 178 Intraoperative photograph depicts a nasogastric
tube perforating the retroesophageal portion of the Nissen wrap.
The placement of this tube was done without communication
between the anesthesiologist and the surgeon, so that direct visu-
alization of the placement of the tube was not done. Direct visual-
ization would allow proper placement of the tube along the greater
curve of the stomach. The nasogastric tube in this case was subse-
quently pulled back, the gastric perforation repaired primarily under
laparoscopic visualization, and the patient had an uneventful post-
operative course.
Repair
Two-layer repair of the stomach or esophagus. Any
LNF patient who, in the rst 24 to 48 hours postop-
eratively, develops an unexplained fever should be ruled
out for an occult GE perforation. In addition, if the
patient develops increasing abdominal pain in the
setting of tachycardia, she or he should be ruled out
for a GE perforation. Having a high suspicion and a
low threshold for assessment of this potentially life-
threatening injury is critical in the post-LNF patient. A
two-layer repair of the stomach or esophagus can be
carried out (see Gastric Injury, Acute or Delayed
[Thermal], earlier).
Prevention
Excellent communication between the anesthesiologist
and the surgeon is required at the time of the bougie
insertion. It is critical that the anesthesiologist and the
surgeon understand this potential complication. The
dilator should be passed slowly and under direct visu-
alization by an individual experienced in this technique.
Placement of the bougie dilator or insertion of the
nasogastric tube was the second most common cause
of gastric and esophageal perforations during LNF
reported by Schauer and associates.10 The risk of esoph-
ageal and gastric perforation has been shown to be
increased during LNF secondary to many factors
including inexperience of both the surgeon and the
anesthesia personnel, absence of manual palpation,
181
Figure 179 Hidden anatomy. The retroesophageal window is
depicted with the potential for injury to the esophagus or stomach
if the dissection occurs too far anteriorly or too far distally. Also
depicted are potential injuries of placement of the nasogastric tube
or the bougie if the GE junction is not properly oriented during
placement and positioning.
improper retraction on the esophagus or stomach, the
presence of an esophageal myotomy, and pathologic
changes of the esophagus. Lowham and coworkers17
clearly showed that lack of communication during
insertion was a primary risk factor for this mechanism
of injury. These authors also suggested that distal
esophageal angulation after crural closure was a primary
risk factor for perforation and needed to be corrected
by anterior and caudal traction on the gastric fundus17
(Fig. 179). Making the diagnosis of postoperative
gastric perforation can be difcult in patients status
post LNF. Hughes and coworkers18 reported one case
in which the diagnosis was eventually made using a
retrograde sinogram through a right upper quadrant
drain placed for an abscess found on computed tomog-
raphy (CT) scan on postoperative day 8, despite nega-
tive Gastrogran and barium swallow studies and a
negative CT scan of the abdomen on postoperative day
3.18 Again, the surgeon must be acutely aware of the
associated risk of occult injury to the esophagus or
stomach that requires diligent assessment to identify
the injury and aggressive management postoperatively.
All patients who develop upper abdominal abscesses or
infectious processes documented by CT scans or other
imaging studies should be suspected of having a gastric
or esophageal perforation until proved otherwise. The
frequency of GE perforation (1%2%) and its severity
(fatal in 20%50%) mandate that it be considered in all
patients with postoperative leukocytosis and fever.18
 182 SECTION III: GASTROINTESTINAL SURGERY

Closure of the Esophageal Hiatus
Aortic Injury
Consequence
Dysphagia
Life-threatening bleeding.
Grade 5 complication
Repair
Energent open primary vascular repair.
Prevention
It is critically important that the laparoscopic surgeon
understand the relationship between the crura and the
aorta, especially the left crus and its close relationship
to the aorta. Needle injuries into the aorta resulting in
death have been reported in addition to other similar
vascular injuries at the level of the aortic hiatus.19,20
Baigrie and associates20 reported three cases of signi-
cant hemorrhage that required conversion to open pro-
cedures for control of hemostasis involving injuries to
the left inferior phrenic vein, an aberrant left hepatic
vein, and the aorta. These authors suggested that
minimal use of hook diathermy for dissection, early
conversion to laparotomy, and early recognition of
aberrant anatomy are critical to prevent vascular injury
that may be life-threatening.20 Visualization and
protection of the aorta during the crus closure, espe-
cially with the most posterior sutures, are critical
(Fig. 1710).
Consequence
Long-term potential difculties with solid foods.
Grade 1/2 complication
Repair
Esophageal dilation or possible reoperation.
Prevention
Dysphagia is a commonly accepted complication of the
Nissen procedure. The classic procedure has been mod-
ied in several waysincluding decreasing the length
of the fundoplication from 4 to 1 cm, dividing the
short gastric vessels, and increasing the size of the
esophageal bougieto minimize the incidence of post-
operative dysphagia. Attempts to eyeball the hiatus
closure have been fraught with difculty because this
commonly leads to dysphagia. To reemphasize the
importance of an esophageal dilator to determine the
size of the hiatus, Patterson and colleagues19 carried
out a prospective, blinded, randomized trial showing
the efcacy of esophageal bougie placement during
LNF. This level-one evidence demonstrated that the

B
Figure 1710 A, The suture has been placed in the most posterior aspect approximating the left and right crura. The aorta sits in close
proximity behind the left crus, and care should be taken with these most posterior sutures to protect against aortic injury at this time.
The aorta (arrow) is seen behind the crus. B, Hidden anatomy. The positioning of the aorta and its relationship to the left and right crus
are shown along with the risk for injury to the aorta with approximation of the left and right crura, especially with posterior sutures. In
addition, the anterior phrenic vessels commonly come in close proximity to the anterior aspect of the hiatus, and care must be taken with
dissection of the anterior phrenoesophageal ligament to minimize injury to these vessels. Lastly, the inferior vena cava is seen posterior
to the caudate lobe, and an aberrant left hepatic artery may be seen in this region, again reemphasizing the potential risk of vascular injury
with dissection of the GE junction.
 17 LAPAROSCOPIC NISSEN FUNDOPLICATION
incidence of long-term dysphagia is reduced in patients
in whom a 56-Fr bougie is used during LNF (17%)
versus patients who underwent LNF without the use
of an esophageal bougie (31% with long-term dyspha-
gia).21 Other causes of dysphagia that can occur post-
operatively include esophageal motility disorders not
detected through preoperative manometric studies, a
tight wrap with poor or inadequate mobilization of
the greater curve of the stomach, and short gastric
vessels.
Breakdown of the Crus Closure
Consequence
Herniation of the wrap into the chest or mediastinum
with pain, possible dysphagia, and recurrent GERD.
Grade 2/3 complication
Repair
Reoperation with reinforcement of the hiatus with
mobilization of the thoracic esophagus to achieve 6 to
8 cm of abdominal esophagus and reinforcement of the
hiatus with biomaterial.
Prevention
Intrathoracic herniation of the Nissen wrap or slipped
Nissen is a commonly described complication after
LNF, typically attributed to inadequate closure of the
crura, excessive tension on the crural closure, or failure
to recognize a shortened esophagus.20 Currently, several
reports discuss the use of synthetic materials to rein-
force the hiatus in LNF, but now, level-one evidence
exists to support its application in hiatal hernias larger
than 8 cm in greatest diameter.2225 In a prospective,
randomized trial, Frantzides and coworkers25 showed
that using polytetrauoroethylene (PTFE) to repair
hiatal hernia defects larger than 8 cm lowered the inci-
dence of breakdown of the hiatus from 22% with
primary crura closure to zero. They also failed to see
evidence of erosions or strictures of the esophagus,
which have been cited as potential pitfalls of mesh
repair of large diaphragmatic hiatal hernias.25 However,
mesh repair is not benign. Granderath and associates23
reported an increased incidence of postoperative dys-
phagia within the rst 3 months in patients who received
mesh hiatoplasty compared with those who received
standard nonabsorbable polypropylene suture hiatal
closure. The signicant difference of the incidence of
postoperative dysphagia between the groups did resolve
at the 1-year follow-up evaluation. Although only case
reports currently exist, biomaterials such as AlloDerm
may prove to be better synthetic agents because of their
capacity to revascularize. Vecchia and colleagues26
demonstrated in the pediatric population that Allo-
Derm may be useful for diaphragmatic repair because
of the potential for broblastic incorporation and small
capillary ingrowth.
183
Suture Placement for the Wrap
Intraluminal Sutures in the Esophagus
Consequence
Ulceration and odynophagia.
Grade 2/3 complication
Repair
Endoscopic removal of the sutures.
Prevention
When sutures are placed to prevent a slipped Nissen,
sutures from the wrap are commonly taken from
the left portion of the cardia through the anterior wall
of the esophagus and then to the retroesophageal
portion of the cardia to complete the 360 wrap. Care
must be taken when placing the esophageal sutures to
get muscularis only and not full-thickness intraluminal
bites.
Other Complications
Gastric Ulceration
Gastric ulceration has been reported as a cause for post-
operative hemorrhage. Etiologies of these ulcerations are
theorized to include trauma to the external wall of the
stomach and/or full-thickness sutures with subsequent
suture erosion and ulceration or from nasogastric or
bougie trauma intraoperatively.27,28 Pianka and cowork-
ers27 reported a case of acute upper gastrointestinal hem-
orrhage from a Nissen wrap ulcer, which they suggested
could result from devascularized segments of the fundus
secondary to division of the short gastric vessels, the sur-
gical dissection, and gastric distention. Cueto-Garcia and
associates28 also reported a case of postoperative gastric
Nissen wrap ulcer in which two surgical clips were found
at the inferior aspect of the ulceration. They concluded
that devascularization from division of the short gastric
vessels and dissection technique in the retroesophageal
space may contribute to postoperative ulceration. Concur-
rent peptic ulcer disease, even when an adequate vagot-
omy has been performed, should be managed medically
postoperatively with proton pump inhibitors to prevent
hyperacidity and hypersecretion, which may also contrib-
ute to postoperative Nissen wrap ulceration.28
At least 15 cases have been reported in the open Nissen
literature of aortoenteric stulas occurring at the point of
the Nissen wrap eroding into the aorta. The cases reported
suggest primary erosion from a gastric ulcer, but the ques-
tion must be raised as to whether any degree of aortic
injury or partial aortic wall tear at the time of the original
surgery predisposed to this disastrous complication. The
damage to the gastric blood supply and the mucosal
barrier that occurs as a result of the trauma of surgery, as
well as the new anatomic proximity created between the
stomach wall and the aorta after LNF, may contribute to
stula formation.29 Gastric ulcers are not the only reported
 184 SECTION III: GASTROINTESTINAL SURGERY
entity to erode into the aorta and result in life-threatening
hemorrhage. McKenzie and colleagues30 reported a single
case of an adventitial aortic granuloma closely associated
with a polypropylene suture placed at the fundoplication.
The authors suggested the use of braided suture for both
fundoplication and crural sutures to prevent the formation
of granulomas and erosion into the aorta.30
Pancreatitis
Pancreatitis from both gallstones and iatrogenic injury
has been reported in patients postoperatively after LNF.
Hughes and coworkers18 suggested that postoperative
pancreatitis typically occurs as a result of blunt pancreatic
trauma and that thin patients may be more susceptible
owing to the limited amount of working space within
the abdomen. The close proximity of the pancreas to
the posterior wall of the stomach is important during
stomach retraction and manipulation of instruments with
retraction.
Liver Hematoma
Because of retraction of the left lateral segment of the liver
to expose the GE junction and hepatogastric ligament,
liver hematomas and retraction injuries are not uncom-
mon but rarely lead to serious complications other than
pain and discomfort. Pasenau and colleagues31 reviewed
retraction injuries associated with LNF and reasserted the
requirement for gentle retraction and use of atraumatic
and blunt instruments to reect the left lateral segment to
allow full exposure. Specically, they asserted that the type
of retractor, the size of the patients left lobe of the liver,
and the force applied on the retractor all contribute to
safe retraction. They suggested monitoring the color of
the retracted liver during difcult cases to indicate when
a pause in the procedure may be appropriate to prevent
ischemia or venous engorgement injuries.31
Cardiac Injury
Beyond the danger of hematoma and infarction during
liver retraction for the LNF, Firoozmand and coworkers32
reported a case of cardiac tamponade resulting from right
ventricular injury secondary to the use and positioning of
the fan liver retractor. They suggested that the acute edge
of the fan liver retractor may have led to the development
of right ventricular laceration because continuous beating
of the heart against the retractor edge contributed to the
formation of a hematoma in the ventricular wall. The
diaphragm is believed to have protected the pericardial sac
from injury, but tamponade resulted when the ventricular
wall hematoma ruptured as the mechnical strain on the
ventricle wall intensied. Firoozmand and coworkers32
suggested careful evaluation of retractor positioning, fre-
quent repositioning of the liver retractor, and early recog-
nition of this fatal complication. An additional report of
cardiac tamponade during LNF indicated that the etiology
of the tamponade was believed to be secondary to right
ventricular injury attributed to damage from a perforating
needle during ventricular contraction.33 Swide and associ-
ates34 reported a second case of ventricular injury second-
ary to direct myocardial trauma from a laparoscopic
instrument. However, their patient did not suffer life-
threatening hemorrhage or tamponade, but experienced
only intraoperative and postoperative electrocardiogram
changes. These two cases demonstrate the need for con-
stant vigilance with laparoscopic instruments, especially
during the critical moments of crus dissection during
the LNF.
Celiac and Superior Mesenteric
Artery Thrombosis
Mitchell and colleagues35 reported a case of celiac axis and
mesenteric arterial thrombosis as the cause of the only
mortality from their series of 156 LNF procedures. They
described a patient with severe postoperative abdominal
pain, leukocytosis, and elevated bilirubin status after LNF
whose clinical picture deteriorated and who required an
exploratory laparotomy. At the time of exploration, the
proximal stomach and lower sixth of the esophagus were
noted to be infarcted and gastric contents were leaking
from all suture sites. The patient recovered from her initial
exploration only to require a second reexploration that
revealed further infarction of the remaining proximal
stomach, gallbladder, spleen, and small and large intes-
tine, sparing the duodenum and proximal jejunum. The
patient eventually expired from hepatic infarction and
overwhelming sepsis. The postmortem examination
revealed a congenitally narrowed ostium of the celiac arte-
rial trunk. Although rare, the danger of mesenteric isch-
emia must be considered during laparoscopic procedures
because CO2 pneumoperitoneum has been shown to
contribute to decreased splanchnic blood ow as a result
of vasoconstriction of the vascular bed and increased
resistance to blood ow across the liver. Prevention of
mesenteric ischemia is best accomplished by avoiding
hypercapnia through increasing minute ventilation and
minimizing insufation pressures (1011 mm Hg).
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1. Rantanen T, Salo J, Sipponen J. Fatal and life-threatening
complications in anti-reux surgery: analyses of 5502
operations. Br J Surg 2000;87:967968.
2. Evans SRT, Jackson PG, Czerniach DR, et al. A stepwise
approach to laparoscopic Nissen fundoplication. Arch Surg
2003;135:723728.
3. Dallemagne B, Weerts JM, Jahaes C, et al. Laparoscopic
Nissen fundoplication: preliminary report. Surg Laparosc
Endosc 1991;1:138143.
4. Jackson PG, Gleiber MA, Askari R, Evans SRT. Predictors
of outcome of 100 consecutive laparoscopic antireux
procedures. Am J Surg 2001;181:231235.
5. Hahnloser D, Schumacher M, Cavin R, et al. Risk factors
for complications of laporoscopic Nissen fundoplication.
Surg Endosc 2002;16:4347.
 17 LAPAROSCOPIC NISSEN FUNDOPLICATION
6. Coelho JCU, Campos ACL, Costa MAR, et al. Complica-
tions of laparoscopic fundoplication in the elderly. Surg
Laparosc Endosc Percutan Tech 2003;13:610.
7. Sydorak RM, Albanese CT. Laparoscopic anti-reux
procedures in children: evaluating the evidence. Semin
Laparosc Surg 2002;9:133138.
8. Powers CJ, Levitt MA, Tantoco J, et al. The respiratory
advantages of laparoscopic Nissen fundoplication. J Pediatr
Surg 2003;38:886891.
9. Skandalakis JE, Gray SW, Rowe JS (eds). Liver. In
Anatomical Complications in General Surgery. New York:
McGraw Hill, 1983; p 110.
10. Schauer PR, Meyers WC, Eubanks S, et al. Mechanisms of
gastric and esophageal perforations during laparoscopic
Nissen fundoplication. Ann Surg 1996;223:4352.
11. Flum DR, Bass RC. The accuracy of gastric insufation in
testing for gastroesophageal perforations during laparo-
scopic Nissen fundoplication. J Soc Laparoendosc Surg
1999;3:267271.
12. Murdock CM, Wolff AJ, Van Geem T. Risk factors for
hypercarbia, subcutaneous emphysema, pneumothorax and
pneumomediastinum during laparoscopy. Obstet Gynecol
2000;95:704709.
13. Joris JL, Chiche JD, Lamy ML. Pneumothorax during
laparoscopic fundoplication: diagonsis and treatment with
positive and expiratory pressure. Anesth Analg 1995;81:
9931000.
14. Khajanchee YS, Hong D, Hansen PD, Swanstrom LL.
Outcomes of antireux surgery in patients with normal
preoperative 24-hour pH test results. Am J Surg 2004;
187:599603.
15. Watson DI, Pike GK, Baigrie RJ, et al. Prospective
double-blind randomized trial of laparoscopic Nissen
fundoplication with division and without division of short
gastric vessels. Ann Surg 1997;226:642652.
16. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S.
Causes of failures of laparoscopic antireux operations.
Surg Endosc 1996;10:305310.
17. Lowham AS, Filipi CJ, Hinder RA, et al. Mechanisms and
avoidance of esophageal perforation by anesthesia person-
nel during laparoscopic foregut surgery. Surg Endosc
1996;10:979982.
18. Hughes SG, Chekan EG, Ali A, Reintgen KL. Unusual
complications following laparoscopic Nissen fundoplica-
tion. Surg Laparosc Endosc Percutan Tech 1999;9:143
147.
19. Leggett PL, Bissell CD, Churchman-Winn R. Aortic
injury during laparoscopic fundoplication: an underre-
ported complication. Surg Endosc 2002;16:362.
20. Baigrie RJ, Watson DI, Game PA, Jamieson GG. Vascular
perils during laparoscopic dissection of the esophageal
hiatus. Br J Surg 1997;84:556557.
21. Patterson EJ, Herron DM, Hansen PD, et al. Effect of an
esophageal bougie on the incidence of dysphagia follow-
185
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ized trial. Arch Surg 2000;135:10551061.
22. Dahlberg PS, Deschamps C, Miller DL, et al. Laparo-
scopic repair of large paraesophageal hiatal hernia. Ann
Thorac Surg 2001;72:11251129.
23. Granderath FA, Schweiger UM, Kamolz T, et al. Laparo-
scopic anti-reux surgery with routine mesh-hiatoplasty
in the treatment of gastroesophageal reux disease. J
Gastrointest Surg 2002;6:347353.
24. Granderath FA, Schweiger UM, Kamolz T, et al. Laparo-
scopic Nissen fundoplication with prosthetic hiatal closure
reduces postoperative intrathoracic wrap herniation:
preliminary results of a prospective randomized functional
and clinical study. Arch Surg 2005;140:4048.
25. Frantzides CT, Madan AK, Carlson MA, Stavropoulos
GP. A prospective randomized trial of laparoscopic
polytetrauoreoroethylene (PTFE) patch repair vs simple
cruroplasty for large hiatal hernia. Arch Surg 2002;137:
649652.
26. Vecchia LD, Engum S, Kogon B, et al. Evaluation
of small intestine submucosa and acellular dermis as
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171.
27. Pianka JD, Smith CD, Waring JP. Acute upper gastroin-
testinal hemorrhage from an ulcer on a Nissen fundoplica-
tion. Am J Surg 1999;177:359363.
28. Cueto-Garcia J, Rodrigues-Diaz M, Salas J, et al. Postop-
erative ulcer and hemorrhage: an uncommon complication
of laparoscopic Nissen fundoplication. Surg Laparosc
Endosc 1998;8:219222.
29. Wasvary H, Wease G, Bierema T, Glover J. Gastro-aortic
stula: an uncommon complication of Nissen fundoplica-
tion. Am Surg 1997;63:455.
30. McKenzie T, Esmore D, Tulloh B. Haemorrhage from
aortic wall granuloma following laparoscopic Nissen
fundoplication. Aust N Z J Surg 1997;67:816818.
31. Pasenau J, Mamazza J, Schlachta CM, et al. Liver
hematoma after laparoscopic Nissen fundoplication: a case
report and review of retraction injuries. Surg Laparosc
Endosc Percutan Tech 2000;10:178181.
32. Firoozmand E, Ritter M, Cohen R, Peters J. Ventricular
laceration and cardiac tamponade during laparoscopic
Nissen fundoplication. Surg Laparosc Endosc 1996;6:394
397.
33. Farlo J, Thawgathurai D, Mikhail M, et al. Cardiac
tamponade during laparoscopic Nissen fundoplication. Eur
J Anaesthesiol 1998;15:246247.
34. Swide CE, Nyberg PF. Cardia trauma: an unusual cause
of dysrhythmias and electrocardiographic changes during
laparoscopic Nissen fundoplication. Anesthesiology 1996;
85:209211.
35. Mitchell PC, Jamieson GG. Coeliac axis and mesenteric
arterial thrombosis following laparoscopic Nissen fundopli-
cation. Aust N Z J Surg 1994;64:728730.
18
Laparoscopic Esophagomyotomy
with Dor Fundoplication
Alexander Wohler, MD and
Stephen R. T. Evans, MD
INTRODUCTION
Achalasia is a rare, acquired disorder characterized by
the triad of aperistalsis of the esophagus, a hypertonic
lower esophageal sphincter (LES), and a failure of
LES relaxation in response to swallowing.1 The primary
pathophysiology in LES hypertension is related to the
destruction of myenteric ganglion cells via an inamma-
tory, possibly infectious, mechanism.2 This process leads
to hypertonicity of the LES and its failure to relax nor-
mally in response to swallowing. The resulting functional
obstruction, which causes dysphagia, leads with time to
abnormal dilation of the more proximal esophagus. In
fact, the abnormalities seen in the peristalsis of the esoph-
agus may be solely a secondary phenomenon related to its
prolonged abnormal distention.2
The gold standard for diagnosing achalasia, after an
appropriate history and physical examination has sug-
gested the disease process, is esophageal manometry,
revealing the triad described previously. Some physicians
choose to start with a barium swallow,2 which can suggest
achalasia as well as evaluate for other disease processes
and anatomic variations that may make endoscopy/
manometry more difcult. An esophagogastroduodenos-
copy (EGD), however, is essential in the preoperative
work-up to evaluate not only for other disease processes
such as malignancy or a stricture (both potential causes
of pseudoachalasia) but also anatomy. Any suspicion of
pseudoachalasia related to a malignant process warrants
a computed tomography (CT) scan and other work-up as
appropriate.
Although multiple nonsurgical treatment modalities
for achalasia exist, none is as effective as denitive
surgical esophagomyotomy, usually performed via a min-
imally invasive technique. The response to pharmaco-
logic agents such as calcium channel blockers and nitrates
is usually poor and short-lived.2 Furthermore, nonsurgi-
cal interventions, such as forceful endoscopic dilation of
the LES and LES botulinum toxin injection, are not
without risk. Okike and coworkers3 found that the risk
of esophageal leak and mediastinal sepsis was four times
higher in those patients undergoing endoscopic forceful
dilation than in those treated with surgical esophagomy-
otomy. In addition, these interventions often increase
the difculty and morbidity of subsequent surgical
myotomy1,4,5 and can also decrease the effectiveness of
the procedure.2
The signicant reduction in operative morbidity afforded
by minimally invasive surgery has increased the attractive-
ness of surgical esophagomyotomy over nonsurgical pro-
cedures. Both video-assisted thoracic surgery (VATS) and
laparoscopic approaches are options, but studies have
suggested that the latter is associated with a shorter
hospital stay, decreased conversion rate, and better
relief of dysphagia.6,7 Most series report a success rate of
approximately 90% or higher in relieving symptoms with
laparoscopic esophagomyotomy.1,4,8 This compares quite
favorably with the long-term success seen with botulinum
toxin injection or pneumatic dilation. Most patients who
receive botulinum toxin injections do not achieve long-
term relief, and the long-term success rate of pneumatic
dilation is only about 65% to 70%.2,9
Although the majority of patients who undergo laparo-
scopic esophagogastric myotomy obtain excellent symptom
relief, the procedure is not without complications. The
operative mortality is low (e.g., <0.5%), if not zero, in
most series. The most common serious complication,
especially if not identied and repaired, is esophageal or
gastric injury with immediate or delayed perforation.
Other complications to be discussed include persistent
or recurrent dysphagia, gastroesophageal reux disease
(GERD), bleeding, and paraesophageal hernia.
INDICATIONS
Symptoms of dysphagia and/or regurgitation
Manometric ndings of: hypoperistalsis of the esopha-
gus, hypertonicity of the LES, and failure of relaxation
of the LES
 188 SECTION III: GASTROINTESTINAL SURGERY

Failure of nonoperative techniques (although initial endoscopic identication of the GEJ (squamocolumnar
operative correction is preferable in the absence of junction) but also is helpful in assessing the mucosa and
contraindications) myotomy after the dissection. The lighted endoscope,
No evidence of pseudoachalasia or advanced mega- with the aid of insufation, allows for inspecting the
esophagus, neoplasia, and the like in preoperative mucosa for small injuries or for residual uncut muscle
work-up that would alter the operative plan bers overlying the mucosa (Figs. 181 and 182). Endos-
copy is also useful in assessing the adequacy of the
myotomy. To that end, some have even advocated intra-
OPERATIVE STEPS operative manometry to ensure the absence of residual
high-pressure zones of the GEJ.9
Step 1 Endoscope placement (left at the gastroesopha-
geal junction [GEJ]) (optional)
Step 2 Positioning and trocar placement
Step 3 Takedown of the hepatogastric ligament/
removal of gastroesophageal fat pad
Step 4 Takedown of the anterior phrenoesophageal
ligament
Step 5 Dissection anterior to the esophagus into the
mediastinum
Step 6 Takedown of the short gastric vessels
Step 7 Esophageal and gastric myotomy
Step 8 Inspection of the mucosa/myotomy
Step 9 Dor fundoplication
Step 10 Trocar removal and closure

OPERATIVE PROCEDURE

Endoscope Placement
Figure 181 Note the presence of residual muscle bers overly-
Many surgeons place an endoscope at the GEJ prior ing the mucosa (black arrow), preventing complete separation of the
to beginning the procedure. This not only allows for myotomy edges (white arrows) in this segment.

Residual
muscle fiber

Figure 182 Residual muscle bers constrict the otherwise

bulging mucosa. Failure to divide these bers (often visually less
obvious than illustrated here) will lead to persistent postopera-
tive dysphagia.
 18 LAPAROSCOPIC ESOPHAGOMYOTOMY WITH DOR FUNDOPLICATION
Positioning/Trocar Insertion
Positioning and trocar placement and insertion are the
same as those used for laparoscopic Nissen fundoplication
(see Section III, Chapter 17).
Trocar Insertion Injuries
Injuries related to trocar insertion are discussed in Section
I, Chapter 8, Laparoscopic Surgery.
Takedown of the Hepatogastric Ligament/
Removal of the Gastroesophageal Fat Pad
Injury to an Aberrant Left Hepatic Artery
See Section III, Chapter 17, Laparoscopic Nissen
Fundoplication.
Takedown of the Anterior Phrenoesophageal
Ligament and Anterior Dissection into
the Mediastinum
Paraesophageal Hernia
In contrast to the dissection performed in an antireux
procedure or takedown of a hiatal/paraesophageal hernia,
the hiatal dissection should ideally remain limited in lapa-
roscopic Heller myotomy.9,10
Consequence
In gaining exposure to the anterior aspect of the
GEJ, not only is extensive (i.e., circumferential) dissec-
tion usually unnecessary, but it also alters the GEJ
physiologically and thereby may predispose to reux.
Furthermore, Chapman and associates9 described a
postoperative paraesophageal hernia as a complication
they encountered with laparoscopic myotomy, which
necessitated repeat operation for repair.
Grade 2/3 complication
Repair
One should inspect the hiatus after completion of the
procedure to ensure that it is not excessively loose. The
presence of a hiatal hernia or a shortened sigmoid
esophagus, for example, may necessitate more thor-
ough dissection around the GEJ than would normally
be required. If the hiatal opening appears loose, it
should be corrected with posterior crural sutures,
keeping in mind that dysphagia may result from a too-
tight closure.
Prevention
Whereas some dissection is needed to expose the
esophagus for an effective myotomy, this should mainly
be performed anteriorly,11 with a minimum of lateral
and posterior dissection. However, some make a small
opening posterior to the esophagus in order to place a
Penrose drain for traction.9 Regardless, the size of the
hiatus and the potential for herniation must be assessed
prior to closure (Fig. 183). This is particularly true if
189
Figure 183 The rather large hiatal opening in this patient pre-
disposes to postoperative gastroesophageal reux (GER) and para-
esophageal hernia. Sutures are placed in the posterior aspects of
the crura to minimize these risks (the rst suture is shown).
a signicant amount of dissection has been necessary,
for example, in those patients with advanced disease
and resulting sigmoid or shortened esophagus.12
Vagal Nerve Injury
See later and Section III, Chapter 17, Laparoscopic Nissen
Fundoplication.
Esophageal Injury
See later and Section III, Chapter 17, Laparoscopic Nissen
Fundoplication.
Pneumothorax, Pneumomediastinum,
and Pneumopericardium
See Section III, Chapter 17, Laparoscopic Nissen
Fundoplication.
Ligation of the Short Gastric Vessels
Ligation of the short gastric vessels allows for gastric
mobilization such that the fundoplication can be per-
formed.1 We perform complete ligation of the short gastric
vessels with the harmonic scalpel. Others advocate limit-
ing this dissection to the more cephalad short gastric
vessels,1,9 presumably in the interest of minimizing disrup-
tion of the LES/GEJ physiology. Regardless, usually at
least some of the short gastric vessels must be ligated in
order to provide enough mobility of the proximal fundus
to complete a fundoplication.
Bleeding
See Section III, Chapter 17, Laparoscopic Nissen
Fundoplication.
Gastric Injury
See Section III, Chapter 17, Laparoscopic Nissen
Fundoplication.
 190 SECTION III: GASTROINTESTINAL SURGERY
Gas Bloat Syndrome
See Section III, Chapter 17, Laparoscopic Nissen
Fundoplication.
Esophageal and Gastric Myotomy
Esophageal or Gastric Perforation
Certainly the most common serious complication of
this procedure, especially if not recognized and repaired
intraoperatively, is that of esophageal or gastric injury/
perforation, which occurs in approximately 5% of
cases.2 The incidence of this complication can be signi-
cantly higher, however (10%), in those who have under-
gone previous pneumatic dilation or botulinum toxin
injection.1,9
Consequence
The most feared complication of the procedure is medi-
astinal sepsis from esophageal leak or perforation
(immediate or delayed). Mediastinal sepsis is particu-
larly dangerous, with a high risk of mortality. There-
fore, protecting against mucosal injury (or identifying
it and repairing it should injury occur) is of utmost
importance. That being said, the key to successful relief
of dysphagia is effective myotomy, which leaves mucosa
as the only barrier between the esophageal lumen and
the mediastinum. This underscores the need for great
caution with respect to avoiding mucosal damage. Fur-
thermore, in addition to frank esophageal perforation,
partial-thickness damage to the mucosa, especially from
electrocautery (Fig. 184), can lead to delayed perfora-
tion, manifesting as mediastinal sepsis postoperatively.
Grade 35 complication
Repair
Detection of mucosal injury is of utmost importance.
Mucosal tears identied intraoperatively should be
Figure 184 The mucosal damage (arrow) occurred during the
myotomy. Although this is not a frank perforation, subsequent
necrosis of this portion of the mucosa may occur, causing a delayed
perforation.
immediately repaired with a sutured closure, which can
be performed laparoscopically, if the surgeon has suf-
cient expertise, but may warrant conversion to an
open procedure in some circumstances. An endoscope
can be very helpful in identifying perforation by using
insufation and transillumination to identify problem
areas of the mucosa. Repaired mucosal injuries or
concern for mucosal damage in the absence of frank
perforation can be effectively buttressed by the anterior
Dor fundoplication,8 which is one of the reasons we
prefer to perform this particular antireux procedure in
conjunction with myotomy.
Postoperative care of patients in whom mucosal injury
occurs includes keeping a nasogastric tube in place past
the GEJ (intraoperatively positioned), nothing-by-mouth
(NPO) status, and antibiotics. These measures are contin-
ued until a postoperative swallow study conrms the
absence of a leak.
Prevention
Although avoiding mucosal injury is of concern in every
patient, the surgeon should be particularly cautious in
those who have had previous esophageal procedures.
Several series have reported a higher incidence of
esophageal injury (some >10%) in patients who have
undergone previous pneumatic dilations.1,4,5
One key to preventing mucosal injury is to minimize
the use of electrocautery during the myotomy. In addition
to causing full-thickness injury, electrocautery can damage
the mucosa (see Fig. 184) such that a delayed perforation
develops. Avoiding the excessive use of cautery will lessen
the chance of mucosal injury, and to this end, a harmonic
scalpel (our preference) or laparoscopic scissors can be
used to complete the myotomy in the cephalad direction.
Ultrasonic dissectors such as the harmonic scalpel are
known to cause less collateral injury to surrounding tissue
than electrocautery. Whereas the use of laparoscopic
scissors eliminates the concern for collateral injury, the
hemostasis afforded by ultrasonic dissectors is a distinct
advantage.
Great care must be taken to ensure that the appropriate
plane is developed between the mucosa and the muscle
bers and that the ultrasonic dissector (e.g., hook electro-
cautery) is pulled away from the mucosa prior to dissecting
the muscle (Figs. 185 and 186). Failure to maintain
sufcient traction away from the mucosa (Fig. 187)
greatly increases the chances of mucosal injury. When
performing the gastric portion of the myotomy, it is
important to realize that the plane just supercial to the
mucosa can be more difcult to identify and develop in
this region. Avoidance of mucosal injury, therefore,
requires meticulous identication of muscle bers and
traction away from mucosa as they are divided.
Incomplete or Healed Myotomy
The most important factor involved in ensuring the effec-
tive relief of dysphagia is the myotomy itself. Incomplete
 18 LAPAROSCOPIC ESOPHAGOMYOTOMY WITH DOR FUNDOPLICATION
myotomy is a major reason for operative failure, as is the
failure to prevent healing of the myotomy by appropri-
ately separating the muscle bers.9,11,13
Consequence
Ineffective relief of dysphagia. Failure to perform a
myotomy that extends appropriately in both cephalad
and caudad directions from the GEJ will lead to early
postoperative failure. Healing of insufciently separated
muscle bers of the myotomy will lead to delayed
failure with recurrence of dysphagia.
Grade 2/3 complication
Repair
An endoscope placed at the GEJ prior to the dissection
allows for the assessment of myotomy completeness.
Figure 185 Proper technique. Note the traction that is placed on
the muscle bers (away from the mucosa) prior to dividing them.
Circular m. layer
Mucosal layer
Longitudinal m. layer
Figure 186 The appropriate technique of retracting
away from the mucosa while dividing the muscle bers.
Also shown is the expected bulging of the mucosa between
the myotomized edges.
191
If, after the myotomy, the endoscope reveals any areas
of remaining constriction, these areas are addressed
with further identication and division of muscle bers
(see Fig. 181). Some have also used intraoperative
manometry to ensure elimination of high-pressure
zones, either at the distal or proximal aspects of the
myotomy or related to initially unidentied residual
muscle bers.9
Postoperative dysphagia can be effectively treated with
pneumatic dilation.11 In order to reduce the risk of
perforation, Zaninotto and colleagues11 recommended
waiting at least 4 months postoperatively before perform-
ing forceful dilation.
Prevention
Accurate predissection identication of the GEJ (i.e.,
by identifying the squamocolumnar junction endo-
scopically) can assist with nding the appropriate start-
ing point for the myotomy. The myotomy should
extend 8 cm proximally and also 2 cm distally onto the
gastric cardia. One should see the mucosa bulging out
from the myotomy site, and any residual muscle bers
seen on the mucosa should be identied and divided.
After the dissection is completed, the edges of the
myotomy should be bluntly dissected away from each
other to lessen the likelihood that they will reapproxi-
mate and heal (Fig. 188).
As mentioned previously, the plane between the mucosa
and the muscle bers can be more difcult to develop
distally at the gastric portion of the myotomy. Also, the
mucosal bulge that results from effective myotomy is
usually less prominent in this region. Both of these factors
increase the risk of incomplete or healed myotomy and
mucosal injury at the distal aspect of the myotomy. One
Anterior vagus n.
 192 SECTION III: GASTROINTESTINAL SURGERY
B cated by postoperative dysphagia.13 A common, perhaps
Figure 187 A, Improper technique. Note the relative lack of
traction placed on the muscle bers (compare with Fig. 185). The
proximity of the lower blade of the instrument to the esophageal
mucosa will increase the risk of direct or collateral damage from
the harmonic scalpel if it is activated in this location. B, Mucosal
perforation due to harmonic scalpel injury identied during the
procedure prior to laparoscopic repair.
should be especially careful, therefore, in dividing the
muscle bers in this region, proceeding in a ber-by-
ber fashion.
Finally, the specic location of the myotomy with
respect to the horizontal plane may be as important to its
effectiveness as is its completeness vertically. Korn and
coworkers14 described the importance of both the semi-
circular clasp muscle bers and the oblique sling
bers in contributing to the tone of the LES. A myotomy
that does not divide both of these bers may be less effec-
tive. To that end, as a general rule the myotomy should
be made slightly to the left of the anterior vagal trunk
(Fig. 189).
Gastroesophageal Reux/Dysphagia
Although minimally invasive esophagomyotomy, usually
laparoscopic, is generally considered the preferred treat-
ment for achalasia, considerable controversy exists regard-
Figure 188 The rather large hiatal opening in this patient may
warrant posterior crural sutures. Also demonstrated are the prop-
erly separated edges (arrows) of the myotomy as well as the resul-
tant bulging of the mucosa from underneath.
ing whether a concomitant antireux procedure is
necessary as well as which type of antireux procedure
should be used.8,15,16 On one end of the spectrum, Ellis
and associates17 and Okike and coworkers3 have advocated
a limited myotomy (extension of the myotomy to only
0.51 cm onto the gastric cardia) without a concomitant
antireux procedure. In contrast, others advocate a full
360 fundoplication.16 Such a fundoplication, in the
setting of an aperistaltic esophagus, can be easily compli-
moderate, practice (and our preferred technique) is to
perform a full myotomy, 8 cm above the GEJ and extended
onto the cardia of the stomach for 2 cm, and then a sub-
sequent Dor fundoplication. This, we believe, minimizes
the risks of both dysphagia (related to incomplete
myotomy or excessive tension from the fundoplication)
and gastroesophageal reux (GER) postoperatively.
Consequence
Failure to provide some barrier to reux often leads to
pathologic GER, whether or not it is symptomatic.
Given the changes that occur in the distal esophagus
from the underlying achalasia, it is possible that only a
fraction of those patients with pathologic reux com-
plain of symptoms, which may be even more concern-
ing, considering the long-term risks of reux with
respect to Barretts esophagitis and carcinoma.
Grade 1/3 complication
Repair
If conservative measures are not effective, postoperative
GER may necessitate reoperation for creating/revising
a fundoplication.
Prevention
We recommend a partial Dor fundoplication, which
has been demonstrated to provide excellent protection
 18 LAPAROSCOPIC ESOPHAGOMYOTOMY WITH DOR FUNDOPLICATION 193

Incision

Anterior vagus n.

Figure 189 The prominence of the oblique sling

bers on the left side of the gastroesophageal junction
(GEJ). Performing the myotomy to the left of midline is
generally recommended to ensure that both the clasp and
the sling bers are divided.

against GERD18 while avoiding the potential complica-

tions of a more circumferential fundoplication. Others
have utilized a 180 posterior Toupet, with good
results. Whereas the Toupet does have the advantage
of being able to prevent a healed myotomy (the fun-
doplication is secured to the edges of the myotomy,
thus theoretically holding the edges apart),1 the ante-
riorly placed Dor protects against esophageal leak by
buttressing the mucosa of the myotomized segment
(Fig. 1810).

Dor (or Toupet) Fundoplication

Dysphagia
Although some controversy exists in the literature regard-
ing the necessity of an antireux procedure after esopha-
geal myotomy,16 it is generally recommended. The
incidence of GER in those who undergo myotomy without
fundoplication has been reported to be as high as 60%.7
However, whereas the myotomy may predispose a patient
to GER, a major concern with including an antireux
procedure is that the very dysphagia that led to the
procedure may persist as a result of an excessively tight
fundoplication. Some authors recommend a oppy
Nissen,16 but we and many others1,4,5,11,12,19 advocate
partial fundoplication. Specically, we perform an anterior
Dor fundoplication.
Figure 1810 Anterior Dor fundoplication buttresses the
mucosa exposed by the myotomy, which protects against the devel-
opment of delayed leak.
Consequence
Excessive LES tension created by fundoplication can
lead to treatment failure. The debate over whether to
perform a fundoplication and which type to employ is
as yet unresolved. Given that the underlying symptom-
atology of achalasia is dyphagia and that esophageal
hypomotility is one third of the diagnostic triad, it
is not surprising that most authors advocate a partial
 194 SECTION III: GASTROINTESTINAL SURGERY
fundoplication only. A complete myotomy followed by
an inappropriately tight fundoplication serves only to
re-create dysphagia. Furthermore, Dor fundoplication
has been shown to be very effective in the prevention
of postoperative GER. In their series, Richards and
colleagues18 reported GER in 47.6% of those patients
who underwent myotomy only, compared with only
9.1% in those who underwent a combined Heller-Dor
procedure.
Grade 2/3 complication
Repair
Intraoperative endoscopy can be used not only to guide
and inspect the dissection but also to evaluate the GEJ
after fundoplication. If the fundoplication leads to
excess resistance to endoscope advancement, it should
be revised.
Prevention
The use of a partial fundoplication, especially the Dor
fundoplication, should not, if done correctly, provide
undue resistance in the LES. Furthermore, in contrast
to the Toupet fundoplication, the anteriorly placed
Dor fundoplication buttresses any potential mucosal
injury and also any mucosal repair that may have been
necessary. Another theoretical advantage of Dor fun-
doplication over the posterior Toupet is that the former
is less disruptive to the physiology of the LES. Bringing
the stomach posterior to the GEJ may angulate the
stomach anteriorly, increasing the likelihood of dyspha-
gia. A fundoplication more circumferential than the
Dor, if performed, should be decidedly loose to lessen
the risk of postoperative dysphagia.
Other Complications
Bleeding
Bonavina and coworkers12 had one patient in their series
who required reoperation secondary to bleeding from
the myotomy site. Although this series dates from before
the laparoscopic era, it seems relevant as a study of the
potential complications of minimally invasive techniques.
Especially when sharp dissection is used to perform the
myotomy, bleeding from the cut surfaces may occur. Elec-
trocautery or suture may be used to obtain hemostasis,
provided that the muscle edges have been sufciently dis-
sected away from the mucosa. Alternatively, an ultrasonic
dissector can be used to complete the myotomy, which is
our preference. Although less collateral damage is gener-
ated with the ultrasonic instruments than with electro-
cautery, one must still be mindful of the potential for
damaging the mucosa and maintain traction away from
the mucosa while performing the dissection.
Anterior Vagal Nerve Injury
The anterior vagal trunk is at risk for injury during the
dissection, myotomy, and fundoplication. Posterior vagal
trunk injuries are much less likely because dissection pos-
terior to the esophagus should be limited, if not avoided
altogether. Although postvagotomy diarrhea and delayed
gastric emptying are more commonly complications of
simultaneous anterior and posterior trunk injury, care
should be taken to identify the anterior vagal trunk. Not
only is it an important structure to preserve, it is also a
landmark for where to perform the myotomy (slightly to
the left of the anterior trunk) (see Fig. 189).
Splenic Injury
Several series have reported splenic injuries,4,12,20 some of
which have required open splenectomy. Whereas splenic
injury is a risk during any laparoscopic procedure (see
Section I, Chapter 8, Laparoscopic Surgery), it is of par-
ticular concern when working near the GEJ and proximal
stomach. Excess traction on the stomach can lead to avul-
sion of short gastric vessels. Retractors and other instru-
ments can also obviously lead to splenic injury. Poor
exposure/visualization of gastrosplenic attachments, espe-
cially when dividing the more cephalad short gastric
vessels, signicantly increases the risk of splenic injury.
Patience (and sometimes an additional port site) is the
best insurance against this problem.
REFERENCES
1. Luketich JD, Fernando HC, Christie NA, et al. Outcomes
after minimally invasive esophagomyotomy. Ann Thorac
Surg 2001;72:19091913.
2. Arain MA, DeMeester TR. Achalasia of the esophagus. In
Cameron JC (ed): Current Surgical Therapy, 8th ed.
Philadelphia: Mosby, 2004; pp 1418.
3. Okike N, Payne WS, Neufeld DM, et al. Esophagomy-
otomy versus forceful dilation for achalasia of the esopha-
gus: results in 899 patients. Ann Thorac Surg 1979;28:
119125.
4. Peracchia A, Rosati R, Bona S, et al. Laparoscopic
treatment of functional diseases of the esophagus. Int Surg
1995;80:336340.
5. Marino M, Rebecchi F, Festa V, Garrone C. Surgical
laparoscopy with intraoperative manometry in the
treatment of esophageal achalasia. Surg Laparosc Endosc
1997;7:232235.
6. Stewart KC, Finley RJ, Clifton JC, et al. Thoracoscopic
versus laparoscopic modied Heller myotomy for achala-
sia: efcacy and safety in 87 patients. J Am Coll Surg
1999;189:164169.
7. Patti MG, Pelligrini CA, Horgan S, et al. Minimally
invasive surgery for achalasia: an 8-year experience with
168 patients. Ann Surg 1999;230:587593.
8. Wang PC, Sharp KW, Holzman MD, et al. The outcome
of laparoscopic Heller myotomy without antireux
procedure in patients with achalasia. Am Surg 1998;64:
515520.
9. Chapman JR, Joehl RJ, Murayama KM, et al. Achalasia
treatment: improved outcome of laparoscopic myotomy
with operative manometry. Arch Surg 2004;139:508513.
 18 LAPAROSCOPIC ESOPHAGOMYOTOMY WITH DOR FUNDOPLICATION
10. Sharp KW, Khaitan L, Scholz S, et al. 100 consecutive
minimally invasive Heller myotomies: lessons learned. Ann
Surg 2002;235:631639.
11. Zaninotto F, Costantini M, Portale G, et al. Etiology,
diagnosis, and treatment of failures after laparoscopic
Heller myotomy for achalasia. Ann Surg 2002:235:186
192.
12. Bonavina L, Nosadini A, Bardini R, et al. Primary treat-
ment of esophageal achalasia: long-term results of myotomy
and Dor fundoplication. Arch Surg 1992;127:222227.
13. Ellis FH. Failure after esophagomyotomy for esophageal
motor disorders. Causes, prevention, and management.
Chest Surg Clin North Am 1997;7:477487.
14. Korn O, Braghetto I, Burdiles P, Csendes A. Cardiomy-
otomy in achalasia: which bers do we cut? Dis Esophagus
2000;13:104107.
15. Streitz JM, Ellis FH, Williamson WA, et al. Objective
assessment of gastroesophageal reux after short esoph-
195
agomyotomy for achalasia with the use of manometry and
pH monitoring. J Thor Cardiovasc Surg 1996;111:107
113.
16. Frantzides CT, Moore RE, Carlson MA, et al. Minimally
invasive surgery for achalasia: a 10-year experience. J
Gastrointest Surg 2004;8:1823.
17. Ellis FH, Crozier RE, Watkins E Jr. Operation for esopha-
geal achalasia. J Thorac Cardiovasc Surg 1984;88:344
351.
18. Richards WO, Torquati A, Holzman MD, et al. Heller
myotomy versus Heller myotomy with Dor fundoplication
for achalasia: a prospective randomized double-blind
clinical trial. Ann Surg 2004;240:405412.
19. Swanstrom LL, Pennings J. Laparoscopic esophagomy-
otomy for achalasia. Surg Endosc 1995;9:286290.
20. Cacchione RN, Tran DN, Rhoden DH. Laparoscopic
Heller myotomy for achalasia. Am J Surg 2005;190:191
195.
19
Laparoscopic Gastric Bypass
Bruce Schirmer, MD
INTRODUCTION
During the 5 years from 1998 to 2003, the eld of bar-
iatric surgery in the United States underwent a veritable
revolution. The number of Roux-en-Y gastric bypass
(RYGB) procedures performed annually in the country
increased from approximately 20,000 to 140,000.1 The
major reason for this may be debatable, but this authors
hypothesis is that the explosion in popularity of the oper-
ation was driven largely by the availability of the perfor-
mance of the operation using a laparoscopic approach.
The temporal relationship of the advent of the laparo-
scopic approach and the rise in popularity of the operation
are strongly correlated. Laparoscopic surgery was popular
among young surgeons, and the popularity spread to bar-
iatric surgery. The public and referring physicians had
already demonstrated the inclination to view a laparo-
scopic approach to surgery as much more acceptable as a
treatment option for operations such as cholecystectomy
and antireux surgery. This pattern continued with
bariatric surgery. Multimedia and the Internet made the
spread of information about laparoscopic gastric bypass
much more rapid and prevalent. Laparoscopic Roux-en-Y
gastric bypass (LRYGB) surgery became one of the most
commonly performed abdominal operations in this
country by the year 2003. During that year, approximately
130,000 gastric bypass operations were performed in the
United States; in 1998, the number was approximately
20,000. The rapid proliferation of the operation resulted
in the need for training opportunities for surgeons inter-
ested in beginning their experience with the operation.
The complications that could occur with an inexperienced
surgeon performing the operation became problematic in
some situations. The large number of procedures per-
formed led to a variety of complications being reported in
the surgical literature. Although these were often not well
quantitated in terms of frequency, the authors own sig-
nicant institutional experience along with the literature
will serve as the primary basis for judging such frequencies,
in instances in which the literature is lacking.
The relative brief duration of performance of LRYGB
in large volume may preclude a true estimation of the
incidence of certain long-term complications, yet the
operation itself, done as an open procedure, has a track
record of over 40 years of careful scrutiny by the bariatric
and surgical community.2 Unless directly related to the
method of access, such long-term complications are as
likely to occur after open as after laparoscopic RYGB.
Therefore, an underestimation of their frequency is less
likely. The literature already supports the fact that two
considerable advantages to the laparoscopic over the open
approach for RYGB are the signicantly lower incidence
of wound complications and the remarkably lower inci-
dence of incisional hernias.3
This chapter is dedicated to assisting the novice bariat-
ric surgeon, as he or she initiates an experience with the
performance of LRYGB, with the hope its contents may
decrease the incidence of complications during that
process. The trainee considering its performance in train-
ing or fellowship will hopefully similarly benet from this
text. The experienced bariatric surgeon may nd these
remarks interesting in a self-comparison assessment of his
or her own experience with the pitfalls of performing
LRYGB.
INDICATIONS
LRYGB is performed to achieve surgically induced
weight loss for patients who are morbidly obese, as
dened next:
Individuals who have a body mass index (BMI =
weight in kg/height in m2) of 40 or greater with
no comorbid medical conditions associated with or
caused by obesity or those with a BMI of 35 or
greater with at least one such comorbidity.4
Individuals should have demonstrated a failure to
lose weight through nonsurgical dietary measures.
Although data to support this indication are lacking,
it is generally accepted.
OPERATIVE STEPS
Step 1 Creation of a pneumoperitoneum
Step 2 Placement of trocars (ports)
Step 3 Laparoscopic survey and assessment of abdomi-
nal organs
 198 SECTION III: GASTROINTESTINAL SURGERY
Step 4 Enterolysis if necessary to free omentum and
clear left upper quadrant
Step 5 Division of small bowel and creation of Roux-
en-Y limb
Step 6 Enteroenterostomy
Step 7 Closure of mesenteric defect
Step 8 Creation of gastric pouch
Step 9 Passage of Roux-en-Y limb
Step 10 Gastrojejunostomy
Step 11 Closure of remaining mesenteric defects
Step 12 Closure of port sites
OPERATIVE PROCEDURE
Creation of a Pneumoperitoneum
Viscus Injury
Consequence
If the injury was created with a Veress needle, it is often
of a relatively minor nature. Tangential laceration may
cause hemorrhage or perforation, leading to leakage,
infection, and peritonitis. If the injury to the hollow
viscus was created by a cutdown to insert a Hassan
trocar, the degree of injury may often be more severe
and the perforation or injury of greater size. Creation
of the pneumoperitoneum with a directly inserted
trocar using visualization through the trocar without
pneumoperitoneum is advocated by some. This
approach, should visceral injury occur, would almost
certainly lead to a more severe degree of injury than
that with the Veress needle, similar to the severity rarely
seen with the Hassan approach. Failure to detect and
repair any signicant size injury often results in severe
peritonitis and sepsis, frequently presenting after dis-
charge. Delay in having the patient return for treatment
often results in the patient representing in extremis, and
mortality is not uncommon.
Grade 15 complication
Repair
Suture repair is indicated if hemorrhage or any appre-
ciable perforation of a hollow viscus is evident. Solid
organ injury with hemorrhage can usually be controlled
with hemostatic energy sources. Extensive injury is
reason for conversion to an open procedure to ensure
adequate repair. Extensive injury may even require seg-
mental intestinal resection.
Prevention
Surgeons who routinely perform laparoscopic surgery
should be well versed in the potential complications
of the creation of a pneumoperitoneum. It is recom-
mended that all surgeons have documented training
and accreditation in the performance of basic laparos-
copy through the completion of the Fundamentals of
Laparoscopic Surgery (FLS) program currently offered
by the Society of Gastrointestinal and Endoscopic Sur-
geons (SAGES).5 FLS instructs all trainees in the
appropriate steps to minimize visceral injury during
creation of the pneumoperitoneum. These steps
include the elevation of the abdominal wall during
Veres needle insertion. In the morbidly obese patient,
this becomes problematic at the umbilical area. We
recommend the use of a tracheostomy hook to elevate
the fascia in the left subcostal midclavicular region,
where underlying viscera are less common and less
prone to injury. Use of this location for creation of
the pneumoperitoneum in the morbidly obese patient
is documented to be safe and effective.6 The Veress
needle is then inserted through the elevated fascia.
Use of a Hassan trocar is discouraged in the morbidly
obese patient because of the large incision needed to
reach the peritoneum with adequate visualization and,
hence, the inability of that site to hold the pneumo-
peritoneum. Previous surgery in the left upper quad-
rant is an indication to insert the Veress needle in the
right subcostal region, with care being taken to avoid
liver injury. We do not favor the direct visualization
technique because, in this authors opinion, its best
aspect is that it allows excellent visualization of the
mucosa of the hollow organ being entered. It is con-
traindicated to use this approach in any area in which
previous surgical scarring is likely.
Vascular Injury
Whereas vascular injury may occur during creation of
the pneumoperitoneum, it is usually more common with
insertion of the trocars, unless the direct visualization
technique is improperly used for creation of the pneumo-
peritoneum. Therefore, this complication is discussed
later.
Gas Embolism
Consequence
Gas embolism, although rare, is a life-threatening com-
plication of creation of a pneumoperitoneum. CO2 gas
is uniformly used to create the pneumoperitoneum
during LRYGB. The solubility of the gas at least allows
the potential for patient recovery if the complication is
immediately recognized and treated. Failure to do so
results in anoxic brain injury, pulmonary or visceral
ischemia, and potentially, death from cardiovascular
collapse.
Grade 15 complication
Repair
The problem arises from insertion of the Veress needle
into an intravascular space. The hemodynamic effects
are similar to that seen with a massive pulmonary
embolism. Sudden decrease in end-tidal CO2 with
accompanying hypoxia and hypotension should alert
the anesthesiologist and surgeon to this problem.
Immediate action is needed. The Veress needle must
be removed, the pneumoperitoneum decompressed,

the patient turned to a right-side-up position, and a
central venous catheter passed to aspirate as much of
the CO2 that still occupies the superior aspect of the
right atrium as possible.
Prevention
Gas embolism occurs essentially exclusively with the
Veress needle approach to pneumoperitoneum. Its inci-
dence is very low, but attention to proper technique in
terms of needle insertion, conrmation of the hanging
drop saline test to ensure the needle is in a free space
of low resistance, and not persisting with insufation at
elevated intra-abdominal pressures on the insufation
monitor will prevent this complication.7
Cardiac Arrhythmia
Consequence
During insufation of the pneumoperitoneum, a not-
uncommon problem is sudden development of cardiac
arrhythmias, usually of the supraventricular type. Bra-
dycardia is the most frequent arrhythmia seen. These
are believed to arise because of the sudden change in
venous return coupled with the change in intra-abdom-
inal pressure. If appropriately managed, these are usually
of little consequence and resolve quickly. However,
persistence can mean conversion to an open operation
for the procedure, cancellation of the operation alto-
gether if too persistent and hemodynamically conse-
quential, and further treatment, including pharmacologic
therapy, as appropriate for bradyarrhythmias.8
Grade 13 complication
Repair
The immediate measure that must be taken is cessation
of insufation of CO2 and full decompression of
the pneumoperitoneum, which normally resolves the
arrhythmia. Occasionally, a pharmacologic agent is
additionally needed. If the patient is suspected to be
hypovolemic, this should be corrected. Once cardiac
rhythm and hemodynamic stability have been achieved,
it is appropriate to cautiously and slowly reinsufate the
abdomen to establish the pneumoperitoneum. In most
instances, this will not result in a return of the arrhyth-
mia. Should the arrhythmia return, the laparoscopic
approach must be abandoned and a decision made by
the surgeon as to whether to proceed with conversion
to an open operation. The latter is appropriate only if
hemodynamic stability occurs with decompression once
again of the pneumoperitoneum.
Prevention
There is no guaranteed method of prevention of this
complication. However, appropriate pharmacologic
treatment of known existing cardiac arrhythmias preop-
eratively, adequate hydration and intravascular volume,
excellent oxygenation, and inquiring about any previ-
ous arrhythmia history are all appropriate measures that
will lessen the incidence of this complication.
19 LAPAROSCOPIC GASTRIC BYPASS 199
Subcutaneous Emphysema
Consequence
Subcutaneous emphysema, including preperitoneal
emphysema, and organ emphysema such as insertion of
gas into the tissue planes of the omentum, are all con-
sidered under this heading. The occurrence of subcu-
taneous emphysema may not manifest itself until later
during a long laparoscopic operation. Insufation of
the preperitoneal space or of the omentum will be
immediately apparent on initial laparoscopic explora-
tion. These latter two problems become issues only if
they prevent the ability of the surgical team to safely
visualize the organs in the operative eld. In this case,
the operation may need to be converted to an open
incision, delayed while the CO2 gas is absorbed, or
cancelled. Rarely do further complications occur. In the
case of subcutaneous emphysema, the increased CO2
load to the patients system can result in systemic aci-
dosis. This may not be apparent simply from the mea-
surement of end-tidal CO2 on the ventilator, which will
be elevated as a result of the emphysema but may
remain static although elevated. In patients with
preexisting cardiopulmonary disease, inability to process
the excess CO2 that is absorbed may lead to a systemic
acidosis with resultant hemodynamic and metabolic
complications.9
Grade 15 complication
Repair
Insufation of CO2 into the preperitoneal space or the
omentum will resolve with time. Placement of the
trocar with the CO2 gas input securely within the peri-
toneal cavity will expedite the resolution of preperito-
neal emphysema by exerting the pneumoperitoneum
pressure on the peritoneal surface, which hastens gas
absorption and decompression. Placement of an arterial
line should be done if one is not in place and the pro-
cedure may be lengthy or if the patient has a history of
preexisting cardiopulmonary disease. Serial arterial
blood gases during the remainder of the operation are
indicated to monitor systemic pH. Subcutaneous
emphysema may occur because the port is only partially
into the peritoneal cavity, causing direct insufation of
CO2 into the abdominal wall. Correction of the port
position is indicated. If systemic pH drops, the opera-
tion may need to be completed using an open
approach.
Prevention
Organ and preperitoneal insufation can best be pre-
vented by attention to technique with Veress needle
insertion and stopping insufation if the pressure rises
to high levels after an amount of insufated gas is less
than expected. Reinserting the needle from the rst
step is indicated in this situation. Subcutaneous emphy-
sema is best prevented by visually conrming that the
port in which CO2 is being insufated has its end
 200 SECTION III: GASTROINTESTINAL SURGERY
securely within the peritoneal cavity. Avoiding reposi-
tioning, removing, and reinserting trocars during the
operation will lessen the incidence of this problem. The
thin elderly patient, with loose subcutaneous tissue, is
at particular risk for the development of subcutaneous
emphysema. Correct port placement technique is par-
ticularly important in these patients, and they should
be carefully monitored for signs of this problem. Arte-
rial blood gas measurement is indicated if the condition
develops and persists. Lengthy laparoscopic procedures
on such patients should be undertaken only when abso-
lutely necessary and with the understanding that sub-
cutaneous emphysema may result in conversion to an
open incision to complete the operation.
Organ Injury
Consequence
Injury to an organ from trocar insertion after or before
the creation of a pneumoperitoneum carries a signi-
cantly higher likelihood of severe injury to the organ
than does penetration with a Veress needle. Repair is
almost always indicated, and the need for conversion
to an open procedure is more likely. Unrecognized
injury to a hollow viscus with a trocar carries an almost
certain likelihood of delayed leak and peritonitis.
Grade 15 complication
Repair
Repair of the injury is as described previously for such
injuries in the section Creation of a Pneumoperito-
neum. The principles are to arrest any hemorrhage
and to repair any hollow visceral wall injury.
Prevention
Placement of trocars using a controlled twisting pres-
sure, with care to avoid sudden rapid advancement of
the trocar through the abdominal wall, is the best means
of preventing this complication. Making an adequate
skin incision such that the skin is not a source of resis-
tance to the trocar insertion is important. Using a
blunt-tip noncutting trocar will decrease but not prevent
such injuries. Placing trocars only once an adequate
pneumoperitoneum exists to serve as a counterresis-
tance to the insertion pressure is also an important
preventive and safety step. The initial trocar placement
must by necessity be a blind maneuver, and this trocar
has the overwhelming likelihood of creating such an
injury. Inspection of the organs in the area of initial
trocar insertion is always mandatory to conrm that its
insertion caused no injury. Subsequent trocars must
always be placed under direct laparoscopic vision.
Vascular Injury
Consequence
The mechanism of vascular injuries is the same as
that for hollow viscus injury: from the uncontrolled
initial trocar insertion into the peritoneal cavity.
Whenever such a situation occurs, the patient is in
a life-threatening situation. This is further com-
pounded if the surgeon fails to realize the presence
of the vascular injury, allowing untreated hemorrhage
to occur. This complication is fortunately rare.10
However, many of the deaths from simple diagnostic
and therapeutic laparoscopic procedures have been a
direct result of vascular injuries from trocar insertion
with resultant hemorrhage, hypovolemic shock, and
death.
Grade 15 complication
Repair
Vascular injury is treated with emergent control of the
vascular injury. Direct pressure, followed by obtaining
both proximal and distal control of the injured vessel,
is indicated. This most often requires an emergent con-
version to an open incision if a major vascular injury
has occurred. Direct suture repair of the vascular injury
is imperative as soon as such control is established.
Ligation is an option if a smaller vessel is injured and
ligation does not lead to untoward consequence. Vis-
ceral ischemia secondary to any vascular injury may
necessitate partial or complete organ removal, as indi-
cated. Major vascular injury is such a severe complica-
tion that accomplishing its repair is usually all the
surgery that should be done at that setting, and of
necessity, the original operation proposed should be
postponed.
Prevention
Prevention of vascular injury is via the same measures
as those used for prevention of organ injury, discussed
previously.
Abdominal Wall Vascular Injury/Hematoma
Consequence
Insertion of a trocar through the epigastric vessels of
the abdominal wall will result in potential uncontrolled
arterial bleeding, at worst, or subsequent abdominal
wall hematoma, at best. This complication may result
in some morbidity to the patient if it is unrecognized
or delayed, usually in the form of a painful and large
hematoma. Intraoperative arterial bleeding is generally
recognized and treated with the usual minor conse-
quence. Failure to immediately recognize it does put
the patient at risk for signicant hemorrhage and hypo-
volemic shock.
Grade 14 complication
Repair
When the epigastric vessels have been lacerated and
arterial bleeding is evident from around a trocar, control
of the hemorrhage can usually be easily accomplished
by passing two ligatures, at right angles to each other

and through the trocar site, using a suture passer. Each
ligature should pass through surrounding tissue of the
trocar opening, encompassing a bite of subcutaneous
tissue, muscle, and fascia. The suture passer is used to
retrieve the end of the suture to form a U-shaped
suture. Two such sutures of permanent material, passed
at right angles to each other and tied over external
bolsters, will normally control hemorrhage from the
vascular injury of the abdominal wall. The more trans-
verse of the two sutures must be placed to occlude the
arterial inow side of the injured vessel. Ligatures
should be pulled up taught before tying to conrm that
they will arrest the hemorrhage. The ligatures can be
removed in 1 to 2 days, as can the bolsters.
Prevention
Maintaining an awareness of the location of the
epigastric vessels during trocar insertion, and avoid-
ing their location and potential injury, is the best
prevention.
Inappropriate Port Placement
Consequence
This complication is mentioned only to conrm its
minimal consequences. Placement of a trocar that sub-
sequently proves to be in a poor location, or in a direc-
tion that is almost useless for performing the operation,
should NOT be viewed as a major problem. A different,
appropriately placed trocar should be inserted as a sub-
stitute. Far more danger arises from trying to
persist in the performance of an operation in which
the trocars limit surgical maneuvering, suturing, or
visualization than does the minimal danger or morbid-
ity of placing an additional trocar. The inexperienced
surgeon is much more prone to persist in using a sub-
optimally placed trocar, to the potential detriment of
the operation.
Grade 1 complication
Repair
Simple insertion of a better, more appropriately placed
trocar is in the patients best interest if it allows safer
and more rapid completion of the operation.
Prevention
Experience with the performance of an operation and
the insertion of trocars will prevent location misplace-
ment and inappropriate direction misplacement of a
trocar, respectively. Trocar placement by experienced
surgeons, or having the senior surgeon present to indi-
cate trocar location, is the best prevention. Under-
standing that an inappropriately placed trocar is NOT
a major problem and that it should NOT necessitate
struggling throughout the remainder of the operation
just to complete it must be a principle taught to all
edgling laparoscopic surgeons.
19 LAPAROSCOPIC GASTRIC BYPASS 201
Laparoscopic Survey and Assessment
of the Abdominal Organs
Missed Abdominal Lesion
Consequence
The initial survey of the abdominal organs done during
LRYGB should constitute a careful assessment of the
liver, intestine, and pelvic organs as appropriate. The
most likely unexpected pathology will be ovarian
tumors in women. These can present as large cysts,
dermoid tumors, or even unexpected ovarian carci-
noma. Uterine pathology, intestinal diverticula, gastro-
intestinal stromal tumors (GIST), and other lesions are
also possible unexpected ndings. The consequence
of missing these lesions is the delay in appropriate
treatment, including excision, which may be indicated,
with the potential for allowing the existence of life-
threatening pathology in the worst-case scenario.
Grade 13 complication
Repair
Repair is not appropriate because this is an error of
omission.
Prevention
The discipline to routinely look at the abdominal
viscera, using a laparoscopic-guided approach, is the
best prevention for missing such lesions. The liver is
generally very obvious, and fatty inltration or injury
as severe as cirrhosis is usually unmistakable. However,
the surgeon must take the time to look in the pelvis
and, especially with women, conrm that there are no
tumors of signicant size that pose a potential threat
to the patients life more severe than the obesity being
addressed at surgery.
Fatty Liver with Cirrhosis
Consequence
Morbidly obese patients are predisposed to develop-
ment of fatty liver and, if long-standing, to nonalcoholic
steatotic hepatitis (NASH). NASH is present when scar-
ring has occurred as a result of the fatty liver inltration.
NASH may progress, in a small number of patients, to
cirrhosis and liver failure. Patients with diabetes are at
the highest risk.11 Determination of disease presence
and severity can help with the prognosis. Severe fatty
liver and hepatomegaly can prevent a laparoscopic
approach to the operation and make an open approach
exceedingly difcult. Cirrhosis is not in and of itself a
contraindication to surgery, although this is controver-
sial. Cirrhosis with accompanying portal hypertension
is a contraindication to proceeding with LRYGB.
Grade 1/2 complication
Repair
No surgical treatment exists for this lesion. Liver biopsy
is always indicated to stage the disease whenever gross
 202 SECTION III: GASTROINTESTINAL SURGERY
fatty inltration of the liver is present. Some authorities
recommend routine liver biopsy. Treatment is medical,
primarily centered upon weight loss.
Prevention
Prevention of fatty liver that can make the exposure of
the stomach for RYGB difcult is done by two mea-
sures. First, patients should have a preoperative abdom-
inal ultrasound to determine liver size and consistency
and whether gallstones are present. Second, if the
liver is fatty, the patient should be placed on a low-
carbohydrate diet for at least 6 weeks. Because liver fat
is derived from the storage of glycogen and triglyceride
from carbohydrate metabolism, a low-carbohydrate
diet will shrink the liver and remove much of its fat
content. Although level-one evidence to this effect is
lacking, numerous personal experiences by bariatric
surgeons with individual cases using this strategy for
successful performance of LRYGB after an initial
aborted attempt have led the bariatric surgical com-
munity to generally accept this practice. However, it
has been shown that visceral obesity was most strongly
correlated with hepatomegaly and steatosis in women
undergoing gastric banding.12 Hepatologists recom-
mend that, for the patient diagnosed with NASH,
ingestion of any substance that is potentially hepato-
toxic should be avoided and weight loss should be
undertaken.
Excessive Adhesions
Consequence
Previous abdominal surgery may result in a large
number of intra-abdominal adhesions, which are
obvious after the initial trocar placement and peritone-
oscopy. The surgeon must decide whether the adhe-
sions preclude a safe and relatively feasible performance
of laparoscopic RYGB or whether conversion to an
open approach is indicated. This decision is one of
individual judgment, based on the surgeons comfort
with laparoscopic adhesiolysis. Severe adhesions may
result in undetected organ injury during the adhesioly-
sis portion of the operation.
Grade 13 complication
Repair
Excessive adhesions may be dealt with using either a
laparoscopic approach or converting to an open
approach. The latter is faster for the adhesiolyis and
must be entertained if the process will be excessively
long laparoscopically. Otherwise, using progressively
placed trocars in locations appropriate for LRYGB, the
surgeon performs the necessary adhesiolysis to free up
the upper abdominal organs and the omentum.
Prevention
Adhesions from a previous operation cannot be pre-
vented. They simply must be overcome. Taking care to
avoid injury to organs during adhesiolysis is the over-
riding concern.
Hernia of the Abdominal Wall
Consequence
Most hernias of the abdominal wall are readily apparent
preoperatively by physical examination. Occasionally,
owing to body wall thickness, unexpected small hernias
may be encountered. They may require repair, which
will lengthen the operative procedure. Failure to repair
them could lead to incarceration of the small intestine
in them postoperatively, Richters hernia. This causes a
mechanical small bowel obstruction that, if untreated,
can result in retrograde distention of the lower stomach
and rupture of the staple lines with consequent perito-
nitis, sepsis, and potentially, death.
Level 15 complication
Repair
Repair is recommended for all hernias large enough
(roughly 1.5 cm) to potentially incarcerate bowel.
Repair is best done using a piece of biologic mesh or
small intestine submucosa for the repair. This material
resists infection and functions well to patch the hernia.
Principles of laparoscopic abdominal wall hernia repair
are followed. For very large hernias, in which incar-
ceration is most unlikely, repair is not indicated at the
time of the initial LRYGB.
Prevention
Preexisting abdominal wall hernias cannot be pre-
vented. The consequences of not repairing them can
be prevented by repairing at the time of LRYGB, if
indicated by the hernia size and location.13
Enterolysis If Necessary to Free the Omentum
and Clear the Left Upper Quadrant
Injury to the Abdominal Organs
Consequence
Consequences of such an event are proportional to its
recognition and correct repair. Should both occur, con-
sequences, other than a prolongation of the operation,
are minimal. Should the injury be severe, resection of
a portion of the organ may be required. This leads to
complications associated with such a procedure. The
most severe consequence is an unrecognized injury
of a hollow viscus. As discussed earlier in the section
Creation of a Pneumoperitoneum, this situation
usually results in a delay in diagnosis of a severe and
life-threatening peritonitis.
Grade 15 complication
Repair
If the injury results in a perforation of a hollow viscus,
repair must be complete, such that postoperative leak

and infection do not occur. Severe injury to a section
of intestine or its blood supply may warrant resection
and reanastomosis.
Prevention
Careful performance of the enterolysis, with good visu-
alization of the tissue to be divided, avoidance of exces-
sive retraction on the scarred tissue, and avoidance
of the use of energy sources near any hollow viscus
are the principles that minimize organ injury during
enterolysis.
Hemorrhage
Consequence
Injury to a vascular solid organ, or to the mesentery
or larger vessels in the abdomen during enterolysis
may produce signicant hemorrhage. This can be
life-threatening.
Grade 15 complication
Repair
Standard measures to control hemorrhage are employed,
including direct pressure, application of energy sources,
and suture ligature. Outcomes are optimal if the injury
is promptly recognized and appropriately treated using
one of these methods. Conversion to an open incision
may be necessary if laparoscopic means are not working.
The need to always have a set of open abdominal
instruments available for all LRYGB cases is empha-
sized by this potential complication.
Prevention
As with prevention of injury to a hollow viscus, the
same principles of excellent visualization, careful tissue
division, avoidance of excessive traction, and avoidance
of any maneuvers outside of the direct visualization of
the camera are the most important measures to prevent
this complication.
Division of the Small Bowel and Creation
of the Roux-en-Y Limb
The ligament of Treitz is rst identied and then the
proximal jejunum is measured for division to create the
Roux-en-Y limb.
Misidentication of the Proximal Jejunum
for Division
Consequence
Failure to recognize the proximal jejunum and to
then begin the operation by dividing more distal bowel
will result in an unnecessary bowel division subse-
quently requiring reanastomosis to repair the problem.
The danger of an extraintestinal anastomosis that
could leak, the increased operative time, and the loca-
tion of a potential postoperative internal hernia are all
19 LAPAROSCOPIC GASTRIC BYPASS 203
consequences of this complication. Should the surgical
team continue with the operation after division of the
bowel considerably beyond the ligament of Treitz, a
signicant malabsorptive component to the operation
will have been created that was not planned for or
wished by the patient. Postoperative deciency in iron
and calcium will almost certainly occur and may be
more refractory to correction with oral supplements.
Steatorrhea, prolic diarrhea as is seen after duodenal
switch operations, fat-soluble vitamin deciency, and
protein calorie malnutrition can all result if the length
of the biliopancreatic limb is excessive and the length
of small intestine beyond the enteroenterostomy is
too short.
Grade 14 complication
Repair
Recognition of the error is the rst and most important
step. Then the surgeon must determine whether the
excess length of the biliopancreatic limb will likely
produce any of the untoward effects noted above. If so,
reanastomosis of the divided bowel is needed and then
repeat creation of the Roux-en-Y limbthis time at the
appropriate distance from the ligament of Treitz.
Prevention
Absolute conrmation of the ligament of Treitz is
imperative to prevent this complication. Factors that
predispose to it and must be avoided include a poor
camera operator who fails to keep the operative eld in
constant vision, excessive scarring making identication
more difcult, and massive obesity similarly making
identication difcult. An inappropriately placed camera
port can also predispose to this. Any time the surgeon
is not clearly seeing the operation, the situation must
be reassessed to correct the reasons. These may include
placement of a more optimal trocar for the camera,
nding a more expert camera operator, and better
coordinating the teams efforts to visualize the ligament
of Treitz.
Tear/Injury in Handling the Small Bowel
Consequence
The potential to tear the small bowel exists in many
stages of the operation, but it is discussed here. If tear
or injury is recognized, appropriate repair minimizes
this complication to simply a few minutes of additional
operating time. If unrecognized, it has the same poten-
tial as any visceral perforation to cause peritonitis,
sepsis, and death.
Grade 15 complication
Repair
Repair must be preceded by recognition. Once the tear
or injury is recognized, the injury is sutured laparo-
scopically to effect a good repair. If conversion to an
open incision is necessary, it should be done. Rarely
 204 SECTION III: GASTROINTESTINAL SURGERY
is such an injury severe enough to require bowel
resection.
Repair of a late, unrecognized injury involves bowel
resection, reanastomosis, placement of drains, thorough
peritoneal lavage, and consideration of creation of an
ostomy proximal to or at the injury site if the tissue quality
is not appropriate for secure anastomosis. Such patients
are usually extremely ill and require the highest level of
intensive care expertise postoperatively.
Prevention
The most important factor in preventing this injury is
the use of good technique by the surgical team when
handling the bowel. Bowel must be grasped with a
large surface area of the grasper, handled gently, and
not pulled excessively. Preoperative bowel preparation
to decompress the bowel improves the lightness of the
bowel and may help decrease this complication,
although no data exist to prove that.
Ischemia of the Tip of the Small Bowel
after Division
Consequence
A mild degree of ischemia can occur after small bowel
division. Resection of the ischemic end of the bowel is
needed. This complication, prevalent enough to not
actually be considered a major adverse event, occurs
because often the bowel mesenteric vessels are not
easily seen through the overlying adipose tissue. They
are divided unevenly, dividing too close to one side of
the divided bowel. That side will suffer ischemia of the
tip of the bowel. If ischemia is recognized and resected,
minimal consequence results. If ischemia is allowed to
persist, it could lead to postoperative breakdown of the
stapled end of the bowel with leakage of bowel con-
tents, peritonitis, sepsis, and death.
Grade 15 complication
Repair
The problem is easily repaired by resecting back to
viable and well-perfused intestine. This may at times
mean several inches of bowel. The resected piece should
be placed in a bag and removed immediately, unless it
is so large as to require trocar site enlargement. Then,
a notation of the presence of the bag must be made so
it is not forgotten at the end of the operation. Reresec-
tion of the bowel is easily accomplished with the use
of the linear stapler for both bowel and mesentery or
with an energy source such as the harmonic scalpel for
the mesentery division.
Hemorrhage of the Small Bowel Mesentery
Consequence
Figure 191 shows division of the small bowel mesen-
tery, maintaining hemostasis. If some bleeding occurred
during mesenteric division, a not-uncommon event, the
surgeon must remain calm and methodically address
Figure 191 Dividing the small bowel mesentery.
the bleeding point or points. Small bleeding areas of
the divided mesentery will often be evident after stapled
division of the mesentery. Treatment is usually accom-
plished with no morbidity. If the bleeding arises from
vessels at the base of the mesentery, in which case the
division of the mesentery was carried down further than
needed, then major bleeding may result that can require
more severe measures for control, transfusion, and may
even rarely be life-threatening if the patient has poor
hemodynamic reserves. Conversion to an open incision
is usually needed in cases of severe hemorrhage.
Grade 15 complication
Repair
Small areas of mesenteric bleeding along the divided
mesentery are easily treated with limited and local
application of the harmonic scalpel for vessel coaptation
and achievement of hemostasis. If the harmonic scalpel
is used for mesenteric division, small vessels will not
usually bleed. If the division of the mesentery is carried
down inappropriately deep into the base of the mesen-
tery, some mesenteric vessels in that area will not be
adequately controlled with a single application of the
harmonic scalpel or a stapler. In these cases, direct
grasping of the mesenteric base to limit blood ow
followed by application of the harmonic scalpel in
several adjoining locations on the vessel or careful
placement of clips or sutures will achieve hemostasis. It
is rare for hemorrhage along the more supercial mes-
enteric edges to be severe enough to require conversion
to an open incision. Major hemorrhage from deeper
vessels will often require this measure.
Prevention
Once the bowel is divided, we usually use the harmonic
scalpel to divide the mesentery. However, the linear
stapler with a white load or gray load will also sufce
to achieve good hemostasis. Careful division of the

mesentery to provide adequate Roux-en-Y limb mobi-
lization but avoid dissection to the very base of the
mesentery, where larger and more difcult to control
vessels exist, is the key to preventing this complication
(see Fig. 191).
Inadequate Length of Roux-en-Y
Limb Mobilization
Consequence
The Roux-en-Y limb will not reach the proximal gastric
pouch, necessitating efforts to later further mobilize it,
which are much more difcult after creation of the
enteroenterostomy and closure of the mesenteric defect.
This risks injuring the distal anastomosis. The Roux-
en-Y limb may just barely reach the pouch, in which
case tension on the anastomosis puts it at high risk for
postoperative leak, resulting in peritonitis, sepsis, and
death.
Grade 15 complication
Repair
The steps to correct this include further division of the
mesentery at the base of the Roux-en-Y limb, with care
being taken to maintain hemostasis but avoid ischemia
to the Roux-en-Y limb. Alternatively, passage of the
Roux-en-Y limb retrocolic (retrogastric if the original
plan was for an antecolic passage) lessens the distance
needed to reach the gastric pouch. If tension is sus-
pected after anastomosis, suturing the Roux-en-Y limb
just distal to the anastomosis to the undersurface of
distal stomach can help alleviate some of the tension
on the anastomosis, especially with patient positional
changes postoperatively.
Prevention
By experience, the surgeon can usually determine
whether mobilization is adequate. We recommend
approximately a 5-inch or longer division of the mes-
entery. Once division is accomplished, but before creat-
ing the enteroenterostomy, a quick check of the
likelihood of the end of the Roux-en-Y limb to reach
above the incisura of the stomach can be performed. If
not, further division and mobilization is needed. For
larger patients (BMI > 60), division of the jejunum at
a point over 50 cm distal to the ligament of Treitz will
provide greater mobility of the Roux-en-Y limb and
should be strongly considered. It is always wise to
prevent this complication rather than to have to deal
with it later in the operation.
Misidentication of the Roux-en-Y Limb Versus
the Biliopancreatic Limb
Consequence
This occurs when the gastric pouch is made rst, then
the jejunum is divided and brought up to do the gas-
19 LAPAROSCOPIC GASTRIC BYPASS 205
trojejunostomy rst, prior to the enteroenterostomy.14
If the biliopancreatic limb is mistakenly identied as the
Roux-en-Y limb and anastomosed to the proximal
gastric pouch, the surgeon then realizes when going to
create the enteroenterostomy, that this has occurred.
Great unhappiness results in the operating room when
it is realized the infamous Roux-en-O has been created.
If the anastomosis is left this way, food would go from
the proximal gastric pouch to the distal gastric pouch.
The proximal anastomosis must be taken down and
redone, and the biliopancreatic limb must have the
anastomosis point resected. Not only is excessive time
spent doing this, but the proximal anastomosis, being
revised, is now much more prone to leak.
Grade 15 complication
Repair
If this complication does occur, the gastrojejunostomy
should be taken down by dividing the biliopancreatic
limb just distal to the anastomosis and resecting as little
as possible of the proximal gastric pouch to remove the
old anastomosis. It is preferable to resect the anastomo-
sis, if the gastric pouch is large enough to allow a stapler
to be placed above the anastomosis. Then that staple
line must be tested for integrity. A new, stapled anas-
tomosis is made between the correct end of the Roux-
en-Y limb and the more proximal part of the gastric
pouch. This new anastomosis should be treated as a
redo anastomosis; a drain is placed adjacent to it, as well
as a gastrostomy in the lower stomach. The biliopan-
creatic limb is correctly repositioned for appropriate
placement and creation of the enteroenterostomy.
Prevention
Creation of the enteroenterostomy usually precludes
this potential complication. To be absolutely certain it
does not occur, once the proximal jejunum is divided
to create the Roux-en-Y limb, a Penrose drain is sutured
to the proximal end of the Roux-en-Y limb, for ease in
later passage as well as for positive identication. The
Roux-en-Y limb must be constantly viewed with the
camera from time of division to attachment of the drain
to prevent misidentication.
Enteroenterostomy
Misalignment of the Bowel to Create the
Twisted Mesentery of the Roux-en-Y Limb
Consequence
Creation of the enteroenterostomy is performed by
aligning a portion of the Roux-en-Y limb, usually from
75 to 150 cm distal to the end of the Roux-en-Y limb,
with the distal end of the biliopancreatic limb. The
alignment must position the Roux-en-Y limb such that
the proximal end is pointed upward toward the head,
so that when it is passed to the proximal stomach the
bowel is straight. Observing from the patients feet, the
 206 SECTION III: GASTROINTESTINAL SURGERY
left side of the Roux-en-Y limb is the side to which
the anastomosis must be made to conform to keep it
straightly aligned. If during the alignment of the bowel
segments, the end of the Roux-en-Y limb is allowed to
slide down toward the feet and the portion of the
Roux-en-Y limb is twisted such that the right side of
the limb is now aligned next to the biliopancreatic limb,
creating the enteroenterostomy with the bowel in this
position will cause a twist in the Roux-en-Y limb mes-
entery as it passes back up toward the stomach. This is
not acceptable, and the anastomosis must be totally
revised. Once again, excessive operating room time is
used, a segment of the biliopancreatic limb and the
Roux-en-Y limb are lost, and there are two stapled
anastomoses instead of one, multiplying the danger of
leakage. Although harder to imagine, if the anastomosis
were so incorrectly created and the twist in the Roux-
en-Y limb not recognized, ischemia of the Roux-en-Y
limb postoperatively could result, along with subse-
quent bowel infarction, peritonitis, sepsis, and death.
Grade 15 complication
Repair
Once recognized, the anastomosis must be resected
and revised. The biliopancreatic limb is divided just
proximal to the anastomosis. There is enough length
of it to create a new anastomosis, given that the usual
length of division of the jejunum is at 30 cm or greater
beyond the ligament of Treitz. It is best to resect the
length of the Roux-en-Y limb involved in the anasto-
mosis, and then perform an enteroenterostomy of the
Roux-en-Y limb to reconstitute it. The new enteroen-
terostomy to the biliopancreatic limb is made a safe
distance beyond this anastomosis. Mesenteric defects
of both anastomoses must be closed at the time of their
creation.
Prevention
When measuring the Roux-en-Y limb for length, and
to determine the place for creation of the enteroenter-
ostomy, the Roux-en-Y limb must always be passed
upward and toward the left upper quadrant while being
measured. This prevents the end from falling toward
the feet. It is mandatory that this stage of the operation
be carefully and constantly viewed by the camera oper-
ator and that the surgeon and rst assistant work
together to effect a safe measurement of the Roux-en-
Y limb while uniformly passing it in this direction.
Once the locations of the two segments of bowel
(Roux-en-Y limb and biliopancreatic limb) are deter-
mined, they are sutured together with a stay suture on
the antimesenteric side. Before the anastomosis is
created, a nal check to prevent this complication
is mandatory to be certain that the Roux-en-Y limb is
not twisted underneath this suture and coming back
through the opening of the area below the bowel
segments.
Misring of the Stapler
Consequence
Misring of the stapler may occur at any time during
the operation. However, in creation of the enteroen-
terostomy, it carries particular potential morbidity.
Injury to the bowel tissue, an incorrectly formed anas-
tomosis, hemorrhage from the bowel edge if cut but
not stapled, stenosis of the anastomosis from rering
over the area again, and leakage of the anastomosis
owing to tissue weakening from two overlapping staple
lines are all potential complications of this problem.
Postoperative hemorrhage, bowel obstruction, and
anastomotic leakage are potential resulting complica-
tions, all of which can be life-threatening.
Grade 15 complication
Repair
The repair needed is based on what results after the
misring. If few staples were red and no tissue divided
(when the cartridge essentially falls off because it was
misloaded), little damage is done and a new ring of
the stapler is performed. It is essential to remove all
unred staples that may be in the way of the new staple
line. Retrieval of the cartridge is, of course, necessary.
If the stapler has divided tissue but the staples are
incompletely red, the damaged bowel must be suture-
repaired to prevent leakage and hemorrhage. If the
staples have red only partially, the loose staples are
removed, a new load is red to create the anastomosis,
and the new anastomosis is both carefully inspected for
integrity of staple line and, if possible, checked for
leakage afterward by milking the bowel contents through
the anastomosis and observing for signs of any leakage.
Reinforcing sutures are always helpful to prevent leakage
after a staple misre at an anastomosis. Conrmation
that the newly created anastomosis is adequate is also
necessary before closing the stapler defect.
Prevention
Fully trained scrub nurses and surgeons who handle the
staplers are the rst and most important prevention.
Loading the stapler correctly and positioning and ring
it correctly are usually the steps violated when stapler
misre occurs. However, there is no question that a
stapler may be defective and misre. All experienced
surgeons have had this occur. The incidence of it is kept
to a minimum by avoiding the human operator errors
noted.
Perforation of the Bowel with the Stapler
Consequence
The surgeon may insert one jaw of the stapler too
forcefully into the lumen, causing a perforation of the
bowel. This most commonly occurs when the bowel
segments are not appropriately aligned and one segment

of bowel is kinked at an angle, allowing the side of the
bowel to be encountered by the advancing jaw of the
stapler. Zeal of the surgeon to make sure the stapler is
inserted to its full length while not observing the bowel
near the tip of the stapler can lead to this complication.
If recognized, it must be repaired; the patient is at risk
for leak from the perforation site. If unrecognized, it
will result in postoperative leak, peritonitis, sepsis, and
potentially, death.
Grade 15 complication
Repair
The perforation is repaired using sutures in most cases.
If a major tear has occurred in the biliopancreatic limb
and sufcient length is available to resect this area and
still have adequate biliopancreatic limb for an anasto-
mosis, resection of the injured section of the biliopan-
creatic limb is best. The repair must be carefully
performed and the damaged area securely closed.
Prevention
This complication is easily prevented by having the
surgeon constantly being able to visualize the stapler
jaws in their entirety. The enterotomies made for the
stapler jaws should be of adequate size to prevent dif-
culty in inserting the jaws. The bowel segments must
be aligned side by side without kinking so that the
stapler jaws can be advanced smoothly into the two
lumens of the bowel (Fig. 192). The process requires
Stenosis of the Enteroenterostomy at Creation
good cooperation on the part of the rst assistant and
camera person to optimally assist the surgeon during
insertion.
Inadequate Closure of the Stapler Defect
Consequence
The defect left by the linear stapler after creating the
enteroenterostomy must be closed securely to prevent
Figure 192 Inserting the stapler the second time, from right to
left, to perform the double-stapling technique.
19 LAPAROSCOPIC GASTRIC BYPASS 207
postoperative leakage of intestinal contents. If not
closed securely, such leakage may result in localized
abscess, potential scarring and obstruction, free leakage
with peritonitis, sepsis, and death.
Grade 35 complication
Repair
Suture closure of the enteroenterostomy stapler defect
has been performed at our center with excellent results.
Some surgeons advocate the double-stapling tech-
nique in which the linear stapler is red both proxi-
mally and distally at the enteroenterostomy site (see
Fig. 192), the stapler defect can then be closed with
another ring of the stapler.15 This will work if the
stapled edges are both held together and totally placed
within the jaws of the closing stapler. We prefer to sew
this defect closed, because the accuracy of suturing
seems more appropriate to this step of the procedure.
No data exist to show whether stapling or suturing is
best. Should any leakage in the stapled or sutured
closure be detected, suture repair is indicated.
Prevention
Careful suturing or stapling techniques to conrm that
a secure and complete closure of the defect made by
the stapler is the only prevention. It is difcult to do a
leak test of this anastomosis, as is commonly performed
for the gastrojejunostomy.
Consequence
Stenosis of the enteroenterostomy, if severe, can lead
to distention of the biliopancreatic limb and the distal
stomach. Because this portion of the stomach has no
pop-off valve, it cannot be decompressed without
intervention. Failure to intervene quickly enough can
result in rupture of the distal gastric staple line with
peritonitis, sepsis, and death.16 Stenosis of the entero-
enterostomy can also cause postoperative vomiting,
which can lead to dehydration, uid and electrolyte
imbalances and acute thiamine deciency if prolonged,
and places stress on the proximal anastomosis.
Emergent operative treatment is usually indicated.
Grade 35 complication
Repair
It is most important for the surgeon to recognize
the problem early in its symptomatic development. We
have found the major value of the postoperative day 1
Gastrogran swallow is to alert us to the potential for
this complication. Whereas percutaneous distal gastros-
tomy placement has been advocated by some as a means
of acutely treating the distal gastric distention,17 we
recommend emergent reoperation. This is usually
accomplished in as rapid a time frame and allows for
distal gastric decompression with an operatively placed
gastrostomy as well as revision of the enteroenteros-
 208 SECTION III: GASTROINTESTINAL SURGERY
tomy. We have found, through experience, that revi-
sion of the anastomosis is advisable unless a clear
alternative mechanical reason, such as a kink in the
distal jejunum just beyond the enteroenterostomy or
another cause of obstruction, is found. Creating a new
enteroenterostomy between the segment of Roux-en-Y
limb just proximal to the existing anastomosis and the
segment of distal jejunum just distal to the anastomosis,
in a side-to-side fashion, is recommended. After the
anastomosis is stapled, but before closure of the stapler
defect, an instrument is inserted into the lumen of the
jejunum to be certain there is still an adequate opening
into the biliopancreatic limb for drainage. The opera-
tion can be accomplished laparoscopically, provided the
distal stomach is not so distended as to preclude this
approach. Also, placing the gastrostomy tube laparo-
scopically is quite feasible, but controlling any spillage
of gastric contents as the tube is inserted can be a
technical challenge without losing the pneumoperito-
neum and visualization of the operation.
Prevention
We advocate using a double-staple technique for cre-
ation of the enteroenterostomy and closing the stapler
defect with sutures. Beginning the suture closure at the
alimentary tract side of the defect will minimize the risk
of a suture catching the back wall of the intestine and
causing narrowing (Fig. 193). We believe this approach
minimizes the risk for postoperative distal anastomotic
obstruction. Mesenteric closure prevents kinking of the
jejunum just distal to the anastomosis (the Brolin
stitch of open gastric bypass).18
Obstruction of the Anastomosis from Edema,
Hemorrhage, or Technical Error
Consequence
This complication is identical to the one just described,
except the lumen is totally obstructed and the etiolo-
Closure of the Mesenteric Defect
Hemorrhage from the Mesentery
Figure 193 Closing the stapler defect with sutures.
gies may be from technical error, edema, or hemor-
rhage with intraluminal hematoma causing obstruction.
The potential complications are identical.
Grade 35 complication
Repair
The principles of repair are identical to those listed
previously (see Stenosis of the Enteroenterostomy at
Creation). However, in some cases in which edema is
suspected to be the cause (swallow study shows minimal
passage initially past the anastomosis), careful monitor-
ing of the patient and conservative treatment can be
justied only if the patient is clinically doing well and
radiographic studies are done that denitively rule out
a dilated distal stomach. Intraluminal hemorrhage will
require the additional operative steps of evacuating the
hematoma from the anastomosis, being sure the distal
jejunum is not similarly obstructed with hematoma,
and directly visualizing the anastomosis staple line to
conrm whether the hemorrhage has stopped. If hem-
orrhage is still ongoing, suture ligature to control it is
indicated. An enterotomy adjacent to the area of the
anastomosis is often the best way to do this. If a new
enteroenterostomy is planned, this may be done with
the stapler insertion site serving as the enterotomy.
Prevention
Prevention is similar to the prevention of stenosis of
the anastomosis listed previously. Hemorrhage at the
time of initial operation that is seen from the lumen of
the bowel must of course be sutured to arrest the hem-
orrhage from the anastomotic staple line. Vomiting
blood postoperatively must alert the surgeon to the
potential for this complication, which needs attention,
as does the hemorrhage itself, which could arise from
either the enteroenterostomy staple line or the gastro-
jejunostomy staple line.
Consequence
Suturing the mesenteric defect closed is mandatory to
prevent postoperative internal hernia. Sutures placed
too deeply into the mesentery may cause hemorrhage
or hematoma. Hemorrhage is rarely of signicant
volume but can require energy or sutures to repair if it
is signicant. These sutures or the compression of a
hematoma may impair blood supply to the jejunum of
the enteroenterostomy, causing it to become ischemic.
The entire anastomosis must then be redone, with
resection of the ischemic area and two new enteroen-
terostomies performed.
Grade 13 complication
Repair
Repair of the bleeding is done initially with direct pres-
sure. If this is insufcient, use of a suture is more likely

to achieve hemostasis. If the bleeding point is very
supercial and easily identied, the harmonic scalpel
may be applied with good effect. If ischemia of the
jejunum occurs, the ischemic portion must be resected.
Treatment is identical to that described in the section
on Misalignment of the Bowel to Create the Twisted
Mesentery of the Roux-en-Y Limb in that a portion
of the Roux-en-Y limb must be resected, the biliopan-
creatic limb cut back, and two new anastomoses
created.
Prevention
Careful suturing technique to take a very supercial,
although lengthy, bite of peritoneum when closing the
mesenteric defect is essential to preventing this compli-
cation. Observation to avoid visible vessels in the mes-
entery with the supercial sutures is also essential.
Ischemia of the Anastomosis
Consequence
The ischemia that may result from a hematoma from
bleeding can also result from sutures placed too
deeply into the mesentery during closure of the mes-
enteric defect. The resulting ischemia has the same
consequence.
Grade 13 complication
Repair
Repair is as described in the section on Misalignment
of the Bowel to Create the Twisted Mesentery of the
Roux-en-Y Limb.
Prevention
As with prevention of hemorrhage, prevention of isch-
emia also requires that the bite of tissue taken is a
supercial one, including just the peritoneum. The
needle must be placed just under the peritoneum and
passed parallel to it to include a sufciently long length
of peritoneum to have strength to hold the suture line
together.
Failure to Close the Mesentery
Consequence
Failure to close the mesenteric defect after a bowel
anastomosis leaves the patient at risk for an internal
hernia. This can cause a closed-loop bowel obstruction
with ischemia and gangrene of a signicant portion of
the small bowel. This is life-threatening. The frequency
of this complication has increased since a laparoscopic
approach to RYGB was instituted.19 This is because few
intra-abdominal adhesions form postoperatively, and
the bowel is more mobile to slide into tissue crevices
like the mesenteric defect. In addition, that defect is
less likely to scar down on its own after a laparoscopic
than after an open operation.
Grade 15 complication
19 LAPAROSCOPIC GASTRIC BYPASS 209
Repair
Closure of the mesenteric defect is performed with
permanent suture placed carefully, to prevent bleeding
or ischemia but to close the peritoneal edges of the cut
mesentery together. Either a running or an interrupted
technique may be used. Exposure of the edges is often
difcult, and this can be a technically challenging
portion of the operation.
Prevention
Prevention is by performing closure with adequate
technique.
Creation of the Gastric Pouch
Hemorrhage along the Lesser Curvature
Consequence
Dissection along the lesser curvature to create an
opening for the stapler jaws to divide the stomach can
be met with hemorrhage. This is usually easily con-
trolled but can, if dissection is misplaced or technically
incorrectly performed, result in signicant hemorrhage
from the left gastric artery or its main branches along
the lesser curvature. If hemorrhage is not easily con-
trolled, this may lead to conversion to an open incision,
signicant blood loss requiring transfusion, and hypo-
tensive shock.
Grade 14 complication
Repair
An experienced laparoscopic surgeon will usually
control this hemorrhage with a combination of com-
pression, application of the harmonic scalpel, and a
suture ligature or an Endo loop.
Prevention
Careful dissection in an area just adjacent to the lesser
curvature surface of the stomach is required to create
an opening for the stapler. The harmonic scalpel is used
for division of smaller vessels along or just supercial
to the gastric surface. Careful spreading dissection from
the right upper quadrant trocar (at the surgeons left
hand) creates the opening in the appropriate orienta-
tion such that the instrument breaks through the peri-
toneum into the lesser sac. Avoiding dissection too far
off the stomach surface and too high up on the lesser
curvature minimizes the risk for severe hemorrhage.
Careful retraction of the mesentery is also necessary to
avoid tearing the vessels.
Division of the Stomach Too Proximal
Consequence
Division of the stomach too close to the gastroesopha-
geal junction leaves inadequate room for a technically
easy gastrojejunostomy. The subsequent difculty in
 210 SECTION III: GASTROINTESTINAL SURGERY
creating an anastomosis close to the esophagus increases
the risk for postoperative leak.
Grade 15 complication
Repair
No repair for this problem once it is created. However,
the anastomosis must be done to the very proximal
stomach or, perhaps, almost directly to the esophagus.
Only a highly procient laparoscopic surgeon should
perform this anastomosis, because it is difcult. Hand
suturing is probably the best option for the anastomo-
sis, but an end-to-end anastomosis stapler could con-
ceivably be used, with the anvil passed through the
esophagus. A linear stapler will not work owing to
inadequate length of the gastric pouch.
Prevention
Careful assessment of the stapler placement before
ring the initial load of staples to start gastric division
is important. The stapler jaws should be approximately
3 cm or more, preferably 4 cm, from the gastroesoph-
ageal junction along the lesser curvature. They can be
placed even further distally, especially if there is concern
that the Roux-en-Y limb may have difculty reaching
the proximal gastric pouch. By having the pouch longer
yet still very small in terms of its diameter, we have not
seen any difference in weight loss between those indi-
viduals who had slightly longer-length gastric pouches
versus those with standard shorter ones. However,
these data are observational impressions only.
Creation of Too Large a Pouch
Consequence
Creation of too large a proximal gastric pouch is not a
major complication in and of itself. However, it will
decrease the effectiveness of the operation, allowing the
patient to eat more and potentially lose less weight. It
also will allow for an increased incidence of both mar-
ginal ulcer and recurrent gastroesophageal reux disease
long-term.
Grade 14 complication
Repair
The pouch can be cut down in size if this complication
is recognized intraoperatively. This is much more easily
done before the creation of the gastrojejunostomy. The
surgeon should assess the pouch, and if she or he
believes it is clearly too large, it should be resected
further to a more appropriate size. If this results
in intersecting staple lines, suture reinforcement at
that point and testing for pouch integrity (leak test)
are advised intraoperatively prior to performing the
gastrojejunostomy.
Prevention
Careful assessment of pouch size as the staple loads are
being red to divide the stomach is crucial. Some sur-
geons use a bougie, a lavage tube, or a Baker tube to
Figure 194 Creating the gastric pouch but taking care to
exclude the fundus. It is best if the Ewald tube can be seen as it
makes a distortion of the proximal gastric pouch.
help size the pouch. Others pass a exible endoscope.
We use a Ewald or gastric lavage tube, placed by the
anesthesiologist under laparoscopic vision and adjusted
to lie along the upper lesser curvature of the stomach.
The tube serves as a guide for pouch size. When
stapling near the gastroesophageal junction to divide
the stomach, the surgeon must be careful to exclude
as much of the fundus as possible, because this part of
the stomach is much more distensible and should
not compose a signicant percentage of the pouch
(Fig. 194).
Stapling across the Tube in the Stomach
Consequence
This unfortunate complication results in a tube that is
stapled and usually divided. The portions of the tube
must be removed from each staple line by resecting
back those sections of the staple line. This allows the
proximal tube to be withdrawn and the distal tube
segment to be removed. Both staple lines, even if
repaired, are now at increased risk for leakage, with the
already dened risks of staple line leakage.
Grade 15 complication
Repair
One hopes this complication is always realized intraop-
eratively, and not postoperatively when the nasogastric
tube is attempted to be removed. Reoperation is
required in the latter case. Repair of this problem intra-
operatively involves resecting enough of each staple
line, usually with a laparoscopic scissors, to allow the
tube segments to be freed up. This is usually less than
a 1-cm length of staples. The defect is then sutured
closed, preferably with a two-layer closure to encom-
pass some of each side of the staple line. A leak test of
the proximal pouch must then be performed. Strong
consideration should be given to placing a laparoscopic
gastrostomy in the distal stomach.

Prevention
This complication is preventable if the surgeon ascer-
tains from the anesthesiologist that the tubes are with-
drawn from the stomach (including nasogastric tubes
as well as temperature probes) before the rst stapler
load is red. If a tube is used to help size and create
the gastric pouch, the surgeon must be certain the tube
position remains where intended and it is not allowed
to shift or be withdrawn slightly and then pushed back
in. This can result in the tube being caught in the
stapler. Direct verbal communication every time with
the anesthesiologist must be done at this step of the
operation. We use a plastic and, hence, see-through
upper drape during our LRYGB procedures, which
visually conrms the act of removing the tubes.
Stapler Misre
Consequence
Stapler misring during creation of the proximal gastric
pouch carries the potential that the area of divided
stomach during the misre is incompletely and inse-
curely stapled. This can lead to postoperative staple line
leak and its already stated sequelae. If the stapler knife
cuts and staples are not red, the gastrotomy created
is a risk for bleeding and leakage and must be
repaired.
Grade 15 complication
Repair
Repair is based on the injury. If a staple line is unstable
or insecure, it must be sutured to prevent leakage. If
there is hemorrhage, it must also be sutured to arrest
it. Any defects in either the gastric pouch or the distal
stomach staple lines must be repaired, reinforced, and
tested (proximal is possible, distal is not). Distal gas-
trostomy may also be needed if there is concern about
the staple line.
Prevention
As mentioned previously for the jejunojejunostomy,
most stapler misres involve operator error. Either the
stapler is misloaded or the amount of tissue attempted
to be divided may be too thick or have preexisting
staples in it that prevent clean ring. These operator
errors are best prevented by training in loading the
stapler as well as in ring and using it. Because staple
misres do occur, there is no absolute way to prevent
this complication.
Hemorrhage from the Staple Line
Consequence
Minor immediate and recognized hemorrhage is easily
treated intraoperatively, with no consequence. Major
intraoperative hemorrhage is rare but is usually also
controlled without the need for transfusion or conver-
sion to an open procedure. Postoperative hemorrhage
19 LAPAROSCOPIC GASTRIC BYPASS 211
can be signicant in volume and can, if sufcient,
subject the patient to hypovolemic shock and its
sequelae. Transfusions may be needed. Reoperation,
endoscopy, and angiography may all potentially be
needed to arrest the hemorrhage, depending on its site
and severity. Intraluminal hematoma from the stomach
that passes to the area of the enteroenterostomy can
cause alimentary tract obstruction and vomiting. If the
distal stomach is the site, it may distend to the point
at which staple lines rupture; massive contamination,
peritonitis, and a high likelihood of death may follow.
Grade 15 complication
Repair
Bleeding that occurs during operation and is identied
can be treated with suture ligature or, for smaller
amounts of hemorrhage, a brief application of the
harmonic scalpel to the vessel lumen site. The most
common site for this occurrence is at the edge of the
lesser curvature during the rst stapler ring. Inspec-
tion of the staple line after creation may demonstrate
small bleeding sites as well. These are similarly treated.
If a patient presents with postoperative tachycardia,
decrease in hematocrit, and a radiographic picture of
distal gastric distention (on computed tomography
scan) or obstruction at the enteroenterostomy (swallow
study), the site of bleeding must be presumed to be the
distal stomach staple line. Treatment is emergent oper-
ative decompression of the distal stomach with a gas-
trostomy tube. We recommend this be done operatively,
although success has been reported with percutaneous
techniques (but for air not hematoma distention).
Oversewing the distal gastric staple line, evacuating
the distal stomach hematoma, and placement of a distal
stomach gastrostomy are indicated.
Hemorrhage from the proximal gastric pouch staple
line will usually manifest itself with hematemesis as the
primary symptom, even before hemodynamic changes
occur. Upper endoscopy and direct endoscopic injection
of the bleeding site is the treatment of choice.20 At the
sign of hemorrhage of any type postoperatively, the
patients deep vein thrombosis prophylaxis must be
stopped and a coagulation panel checked to be certain
that no element of coagulopathy is contributing to the
problem.
Prevention
The incidence of postoperative signicant hemor-
rhage after LRYGB is under 3% and includes all types
and sources of hemorrhage.21 Measures to prevent
gastric staple line hemorrhage include a careful intra-
operative inspection of these staple lines and avoiding
overdosing any postoperative anticoagulation medica-
tion (including using any combinations that may be
synergistic such as coumadin and low-molecular-weight
heparin, given in therapeutic doses simultaneously).
Aggressive management of hemorrhage can minimize
the complications.
 212 SECTION III: GASTROINTESTINAL SURGERY
Leak from the Staple Line
Consequence
Gastric staple line leakage postoperatively can result in
massive peritonitis, sepsis, and death. Smaller, more
contained leakages may result in intra-abdominal
abscesses, often in the left subphrenic region.
Grade 35 complication
Repair
Distal gastric staple line leaks. Recognition of the
problem is the major obstacle to appropriate and timely
care. The diagnosis of a distal gastric staple line leak is
made more difcult by the fact that an oral gastrogra-
n swallow study, considered the standard test for leaks
from the gastrojejunostomy or proximal gastric pouch,
will be normal in this setting. A high index of suspicion
and any untoward signs such as unexplained tachycar-
dia, tachypnea, excessive abdominal pain, fever, and
persistent oliguria are all tips to the potential presence
of this problem.22 Distal gastric distention from bilio-
pancreatic intestinal limb obstruction and distention
must raise the immediate suspicion of this problem
existing or potentially occurring. Repair of distal gastric
distention is via immediate operation, usually open but
laparoscopic can be appropriate in some settings, with
closure of the staple line, thorough lavage and elimina-
tion of contaminating uids in the abdomen, and place-
ment of a gastrostomy tube in the distal stomach.
Leakage from the proximal gastric staple line is treated
identically as leakage from the gastrojejunostomy,
described later.
Prevention
There is, unfortunately, no guaranteed method of pre-
Ischemia of the Proximal Gastric Pouch
venting this complication entirely. Major series of
LRYGB report leaks, which would include this site, at
from 1% to 5%.23 Careful intraoperative attention to
successful and complete division and closure of the
stomach is the most important step. If staple misre,
staple line bleeding, or other problems arise to suggest
that the staple line could be compromised, our approach
is to be as certain as possible that excellent closure of
the staple line has occurred intraoperatively (including
testing the proximal pouch if indicated) and consider-
ation of placement of a drain in the area as well as a
distal gastrostomy, depending on the concern for the
staple line integrity.
Although the drain and gastrostomy may not prevent
the leak, they can be useful in its management.24
Inadequate Division of the Stomach
Consequence
Inadequate division of the stomach leaves an isthmus
of intact stomach, always at the area of the greater
curvature near the angle of His. This passageway allows
for decompression and, hence, defeat of the process of
proximal gastric restriction of intake of food. It also is
a pathway for distal gastric juice, causing a high inci-
dence of marginal ulcer when present.
Grade 14 complication
Repair
The situation in which this usually occurs is in the very
superobese patient undergoing LRYGB, in whom visu-
alization of the area of the angle of His is difcult. BMI
alone may not be an accurate reection of this dif-
culty: men with central obesity and a BMI of 50 may
be more difcult than a woman with a hips-and-but-
tocks fat distribution pattern and a BMI in excess of
70. Once recognized, treatment depends on the resul-
tant symptoms from the remaining gastric communica-
tion. If weight loss is suboptimal or if a marginal ulcer
develops, reoperation to complete division of the
stomach is indicated.
Prevention
The best means of preventing this complication is to
ensure the surgeon and the whole operating team see
the two sides of the completely divided stomach at the
area of the angle of His. If liver retraction prevents this,
a second liver retractor should be placed. If telescope
position is not optimal, an additional port should be
placed to allow good visualization of the area. If these
measures fail, conversion to an open incision may be
necessary to accomplish this task, although the expo-
sure and visualization using that approach are often less
optimal than the laparoscopic approach, in this authors
experience.
Consequence
Fortunately, the stomach is very vascular, and this com-
plication is rarely seen or reported. If it occurs, the
surgeon must have ligated the left gastric artery near
its takeoff. If recognized, resection of the remaining
stomach and esophagojejunostomy is indicated. This is
an operation with at least a ve times higher leak rate
for the anastomosis.25 If unrecognized, the ischemic
gastric pouch will break down and a postoperative anas-
tomotic leak, with its potentially lethal result, will
occur.
Grade 25 complication
Repair
The repair is hopefully done during the original opera-
tion when the condition is recognized. Reports of this
are so scarce as to make it an extremely unlikely com-
plication. If it occurs, the gastric pouch must be resected
back to viable tissue, likely the distal esophagus, and an
esophagojejunostomy performed. This anastomosis,
because of its high potential for leak, should be treated

by placement of a perianastomotic drain and a distal
gastrostomy tube. Conversion to an open operation
may be needed to accomplish all these tasks.
Prevention
Avoiding hemorrhage from the upper lesser curvature
of the stomach during dissection for initiating the cre-
ation of the proximal gastric pouch is the key preventive
step. Only if the left gastric artery and its main feeding
vessels to the proximal stomach are totally ligated
would this result occur. This is unlikely, but avoidance
during mesenteric dissection is key.
Passage of the Roux-en-Y Limb
Injury to Colon
Consequence
If recognized and repaired successfully, there is minimal
consequence. If unrecognized or inadequately repaired,
colonic contents leaking postoperatively will cause fecal
peritonitis, sepsis, and potentially, death.
Grade 15 complication
Repair
Recognizing that this has occurred is key. In the ret-
rogastric passage of the Roux-en-Y limb, this is unlikely
unless there is difculty, the gastrocolic ligament is
opened to visualize the lesser sac, and the opening is
made too close to the colon and causes injury. In the
antegastric approach, usually the omentum is divided.
At the base of that division, extending it too far can
cause colon injury. Once recognized, the injury is
usually small enough that two-layer suture repair is
appropriate and satisfactory.
Prevention
Using the retrocolic approach, keeping the mesenteric
opening at the base of the mesentery, and being careful
to avoid opening the gastrocolic ligament very far from
the greater curvature of the stomach (the ideal location
is just beyond the gastroepiploic vascular arcade) will
prevent this injury. Using the antecolic approach,
halting omental division before the surface of the colon
is encountered is imperative.
Injury to the Stomach
Consequence
Injury to the stomach, from the harmonic scalpel or
traction injury, can potentially result in postoperative
gastric necrosis and leak. The same consequences as for
anastomotic leak would follow.
Grade 15 complication
Repair
Repair of any gastric injury should be by immediate
suturing, usually with an imbricating suture, to buttress
19 LAPAROSCOPIC GASTRIC BYPASS 213
the injury site and avoid postoperative perforation and
leakage. The incidence of this injury is extremely low.
Prevention
Prevention of injury to the stomach is by clearly visual-
izing any use of an energy source in the creation of a
mesenteric opening to the lesser sac. Avoiding touch-
ing the stomach with the energy source will prevent
this complication. Similarly, avoiding excessive traction
on the stomach that could result in an injury to its wall
is also imperative.
Hemorrhage
Consequence
During retrocolic advancement of the Roux-en-Y limb,
an opening is made in the mesentery of the transverse
colon. If that opening is made through a major vessel
of the colon mesentery, signicant hemorrhage may
occur. This can lead to the need for further surgical
maneuvers to stop it, at best, or conversion to an open
operation and signicant blood loss with consequent
hemodynamic shock, at worst.
Grade 15 complication
Repair
If hemorrhage from the colonic mesentery is encoun-
tered, it must be controlled with direct pressure and
grasping. Then either use of the harmonic scalpel (for
a vein or smaller artery) or clips or sutures (for larger
arteries) will affect an adequate control of the bleeding.
If the bleeding has caused hemodynamic changes,
appropriate uid resuscitation and transfusion should
be performed as indicated.
Prevention
Creating a defect in the transverse colon mesentery that
will minimize the risk of bleeding can be done if the
defect is made just to the patients left of the ligament
of Treitz and relatively low on the surface of the under-
side of the transverse colon mesentery. Staying to the
patients left of the ligament of Treitz usually prevents
injury to the middle colic vessels. Keeping the mesen-
teric defect relatively low on the transverse colon mes-
entery avoids the often-present large crossing vessel in
the upper portions of the colon mesentery (marginal
artery of Drummond or other crossing vessels that may
exist and be unnamed).
Inadequate Length of the Roux-en-Y Limb
Consequence
If the Roux-en-Y limb will not stretch up to
meet the proximal gastric pouch, the operation is
already in trouble. Because the proximal gastric
pouch is likely already created, it cannot be revised to
make it longer. The mesentery of the jejunum must be
 214 SECTION III: GASTROINTESTINAL SURGERY
further undercut to mobilize the Roux-en-Y limb
further, and this presents the potential for bleeding and
ischemia. Finally, once the anastomosis is created, it
may be under tension, increasing the risk for leakage
postoperatively.
Grade 15 complication
Repair
If the Roux-en-Y limb is not long enough to reach the
proximal gastric pouch, it must be further mobilized.
If the distal anastomosis has already been performed,
this task becomes very difcult. The mesenteric closure
must be taken down. The mesentery then must be
further divided to allow enough mobilization of the
Roux-en-Y limb to reach the proximal gastric pouch.
This can be a difcult technical maneuver, fraught with
the potential for hemorrhage or ischemia to the exist-
ing Roux-en-Y limb or biliopancreatic limb.
Prevention
Adequate mobilization and length of the Roux-en-Y
limb must be ascertained early in the operation when
this maneuver is performed. Experience will usually
allow the surgeon to visually assess whether the
bowel will reach the proximal stomach. If any doubt
exists, simply attempting to bring the bowel up to
the proximal stomach immediately after creating the
Roux-en-Y limb will conrm adequate length. We have
found that in patients with high BMI, the bowel mes-
entery can be short and the distance to the stomach
longer. In these patients, we construct the gastric pouch
longer, starting just above the incisura, to decrease the
distance the Roux-en-Y limb must reach. The pouch
can be cut back if the limb is long enough to reach
higher.
Twist of the Roux-en-Y Limb Mesentery
Consequence
The Roux-en-Y limb must be passed upward to the
proximal gastric pouch with no twists in it or its mes-
entery. Such undetected twists may result in postop-
erative ischemia, gangrene, necrosis, leakage of
intestinal contents, peritonitis, sepsis, and death.26
Twists may also cause partial to complete bowel obstruc-
tion. Ischemic stenosis may occur over a longer time
frame if none of the these manifest themselves rst.
Grade 15 complication
Repair
If the twist is discovered prior to creation of the gas-
trojejunostomy, the Roux-en-Y limb is simply untwisted.
If it is discovered at surgery after creating the anasto-
mosis, the anastomosis must be taken down and revised
after untwisting the Roux-en-Y limb. In our experi-
ence, this usually requires conversion to an open inci-
sion and puts the revised gastrojejunostomy at higher
risk for leakage.
Figure 195 Passing the Roux-en-Y limb with emphasis on being
sure the mesentery is downward.
Prevention
During passage of the Roux-en-Y limb, the entire sur-
gical team must focus on the fact that the mesentery
of the limb is straight and not twisted. Imaging the
mesentery during passage is important to conrm
this. Using a retrocolic approach, which we do for
LRYGB, the passage of the end of the Roux-en-Y limb
into the lesser sac is carefully done to maintain the
mesentery location straight downward (Fig. 195).
Once the Roux-en-Y limb is passed up after dividing
the stomach, the orientation of the limb must be iden-
tical to that which it had previously: the mesentery
down, the staple line pointing toward the patients
right side as it is brought up to just clear the distal
stomach. If this is not true, the gastrocolic ligament
must be opened to clearly visualize the entire Roux-en-
Y limb and its mesentery, and the area at which the
Roux-en-Y limb passes through the transverse colon
mesentery must also be visualized to conrm appropri-
ate orientation.
Roux-en-Y Limb Obstruction at
the Colonic Mesentery
Consequence
This complication occurs only with the retrocolic route
of the Roux-en-Y limb. The mesenteric opening may
be too tight or, more likely, later postoperatively
develop scarring at the opening that kinks or narrows
the Roux-en-Y limb. Partial to complete bowel obstruc-
tion can occur, with the need for reoperation to revise
this area.
Grade 24 complication
Repair
The opening in the transverse colon mesentery must
be adequately large to allow the Roux-en-Y limb to pass

through it without constriction. If scar tissue has devel-
oped to form a constricting ring about the opening, it
must be divided to alleviate the obstruction. If the
surgeon used a running permanent suture to close
the mesenteric opening, it can result in stenosis at the
mesenteric opening. This suture must be divided and
the resultant scar released. If the Roux-en-Y limb was
not appropriately sutured to the mesentery at surgery,
partial herniation of the limb into the retrogastric space
can mimic the same types of obstructive symptoms as
can scarring at the mesenteric opening. Reduction and
resuturing of the bowel is indicated.
Prevention
Creating an adequate mesenteric opening, then sutur-
ing the bowel to it appropriately with interrupted per-
manent sutures will prevent this complication.
Gastrojejunostomy
Stapler Misre
Consequence
Staple misring to create the gastrojejunostomy
carries the same potential problems as it does for the
jejunojejunostomy. In addition, it is particularly hard
to correct this problem at the gastrojejunostomy site
because only a small amount of gastric tissue is available
for a new staple ring. A new stapled or a revised hand-
sewn anastomosis must be created after the misring.
This may involve conversion to an open procedure.
Increased chance for postoperative leakage exists, the
consequences of which were well dened previously
(see Creation of the Gastric Pouch, Stapler Misre).
Grade 15 complication
Repair
The repair required is based on the tissue injury caused
by the misre. If it is minimal, a new staple load may
be red carefully, ensuring good tissue apposition and
visually inspecting the anastomosis for competence and
security. A postoperative leak test is indicated after
closing the stapler defect. More severe injury to the
tissues could require resecting back a portion of the
gastric pouch or Roux-en-Y limb or both and creating
a new anastomosis. If not enough gastric tissue is avail-
able and an opening exists in the gastric pouch, a hand-
sutured gastrojejunostomy is the best option for
constructing the anastomosis. Placement of a perianas-
tomotic drain and a distal gastrostomy should be con-
sidered if the revised anastomosis is considered high
risk for leakage.
Prevention
Prevention is similar to that for stapler misrings,
described previously for the jejunojejunostomy. There
is no absolute prevention.
19 LAPAROSCOPIC GASTRIC BYPASS 215
Leak from the Anastomosis
Consequence
Postoperative leaks from the gastrojejunostomy repre-
sent the most frequent site for leaks after LRYGB.27,28
Leaks here pose the same risks to the patients health
as in the other areas described previously (jejunojeju-
nostomy and gastric staple line). Leaks may persist for
months despite reoperation and closure.
Grade 15 complication
Repair
The signs and symptoms of a leak are the same as that
of leakage from the gastric staple line described previ-
ously. A high index of suspicion must be maintained
by the surgeon for any patient with any such symptoms.
Aggressive evaluation includes an emergent swallow
test, which even if negative does not rule out the chance
for a leak because these are known to be inaccurate in
a signicant percentage of cases. Persistence of any
untoward signs suggesting a leak is indication for emer-
gent reoperation. If a leak is found, oversewing, but-
tressing the repair with tissue such as omentum,
thorough drainage of the area, and placement of a distal
gastrostomy are indicated. The surgeon must be pre-
pared to care for a potentially very sick patient postop-
eratively, and all available intensive care facilities and
consultants should be appropriately used as indicated.
Persistent stulas may require many weeks to close, and
drains should be monitored until no further output is
seen. Then a swallow test should be conducted to
conrm no further leak before oral intake is restarted.
Enteral feeding via gastrostomy during the recovery is
indicated. Recent evidence suggests leaks from the gas-
trojejunostomy may be treated with a high rate of
success using an endoscopically placed stent. Stent
migration is the major complication when such an
approach is used.29,30
Prevention
Use of good technique to create the anastomosis is the
best prevention (Fig. 196). Having no tension on the
Figure 196 Creating the proximal stapled anastomosis with the
linear stapler. The stapler is in place, ready to re.
 216 SECTION III: GASTROINTESTINAL SURGERY
anastomosis, having a cleanly red stapler to create it,
and careful oversewing of the staple defect are all nec-
essary. Good blood supply to both the stomach and
the Roux-en-Y limb is important. An intraoperative
leak test is highly recommended. Despite these mea-
sures used by surgeons, the leak rate after LRYGB is at
or over 1% in most series, indicating that even these
measures do not guarantee that this complication
cannot occur. However, because it is the leading cause
for postoperative legal action against bariatric surgeons,
the surgeon is wise to follow all precautions. In addi-
tion, maintaining a high index of suspicion for a leak
postoperatively will improve the likelihood it is promptly
diagnosed and treated, and thus minimize complica-
tions from it.
Tension on the Anastomosis
Consequence
Finding that the anastomosis is under some tension
at the time of its creation poses the risk for a higher
incidence of postoperative leakage. This leakage can
result in peritonitis, sepsis, and death, as described in
the section Leak from the Anastomosis.
Tension on the anastomosis may also result in post-
operative stenosis of the anastomosis from chronic
ischemic stricture. This typically presents 6 to 12 weeks
postoperatively with symptoms of vomiting and food
intolerance.31
Grade 15 complication
Repair
The repair is based on the degree of tension. If only a
very small amount exists, we suture the Roux-en-Y limb
to the side of the proximal gastric pouch (done in all
cases), and that process provides us with further feed-
back on the tension, if any, present. If after creating
this suture line, the tension issue seems resolved, we
proceed with anastomosis. If the tension seems too
severe before creating the anastomosis, we proceed to
lengthen the Roux-en-Y limb as described previously
under Inadequate Length of the Roux-en-Y Limb.
A leak test is always done.
Prevention
Prevention involves recognition of tension and alleviat-
ing the situation. The same measures indicated for
preventing an inadequate length of the Roux-en-Y
limb, described previously, should be followed here as
well.
Hemorrhage from the Anastomosis
Consequence
Hemorrhage from the gastrojejunostomy during
surgery requires suture ligature repair or harmonic
scalpel energy to stop the hemorrhage. Care must be
taken to avoid tissue necrosis or stenosis of the anasto-
mosis during this process. Hemorrhage postoperatively
can result in hematemesis, aspiration, need for hospital-
ization and transfusion, hypovolemic shock, and need
for endoscopic or even operative measures to arrest the
hemorrhage. Hemorrhage can be life-threatening.
Grade 15 complication
Repair
Repair involves stabilization of the patient, assessment
for amount of blood loss, resuscitation with intrave-
nous uids and blood products as indicated, ruling out
any coagulopathy, and aggressive use of upper endos-
copy to assess the bleeding site and perform epineph-
rine injection to arrest the bleeding.20 Other endoscopic
measures such as heater probe or bicap cautery may be
used but are less advisable because of a higher likeli-
hood of tissue injury leading to perforation. Operative
suturing of the anastomosis is indicated if endoscopic
measures fail.
Prevention
There is no absolute prevention for this problem, as
noted previously for hemorrhage from the gastric staple
line. Oversewing or use of suture line buttress materials
to perform the anastomosis has not been shown to
totally eliminate this complication. The incidence of
this complication is fortunately low, probably in the 1%
range.23 Noting and treating intraoperative suture line
bleeding is important to prevent postoperative prob-
lems from large amounts of blood loss.
Stenosis of the Anastomosis
Consequence
Stenosis of the gastrojejunostomy may present very
early after surgery (postoperative days 12) from edema
or technical error in creating too small an anastomosis.
Subsequent stenosis usually presents at 6 to 12 weeks
postoperatively, but later presentation is possible asso-
ciated more with concurrent marginal ulcer and the
edema and scarring from it.31 Stenosis causes nausea,
vomiting, food intolerance, dehydration, electrolyte
disturbances, acute thiamine deciency, and even renal
injury if dehydration persists too long. Thiamine de-
ciency can produce permanent neurologic decits such
as Wernickes encephalopathy picture if not appropri-
ately treated.32 Endoscopic, uoroscopic, and operative
procedures may be needed to treat this problem.
Protein calorie malnutrition may also evolve if stenosis
is chronic and untreated.
Grade 15 complication
Repair
Usually, the problem is suggested by the patients
symptoms. If highly suspected, we recommend an
upper endoscopy to both diagnose and treat the
problem. Endoscopic balloon dilation is indicated for

any anastomosis with a diameter less than 10 mm,
essentially one that does not allow the scope to pass
through. Usually one or two dilations will sufce to
treat the stenosis, but further dilations may sometimes
be needed. A uoroscopic dilation may be indicated
if more than one endoscopic dilation has failed, because
the radiologist can use a larger-diameter balloon than
can the endoscopist. Reoperation is rare; in our experi-
ence, it is limited to those few patients with associated
marginal ulcers that failed to heal without severe
stenosis.31 Any patient who presents postoperatively
after a bariatic operation, including LRYGB, should be
given intravenous thiamine and B vitamins (similar to
treatment for alcoholism) before the administration of
intravenous glucose. Fluid resuscitation, electrolyte
replacement, and even short-term parenteral nutrition
may be indicated depending on the severity of dehydra-
tion and malnutrition seen.
Prevention
The incidence of gastrojejunostomy stenosis after
LRYGB can be minimized by several measures. The
type of stapler used to create the anastomosis has been
related to the incidence of stenosis.33 The linear stapler
is associated with an exceedingly low incidence of this
problem (<1% in our recent experience34) The use of a
circular stapler is associated with an incidence of
between 9% and 14% stenosis.35 Smaller-circumference
circular staplers are associated with the higher end of
this spectrum. Hand-sewn anastomoses are associated
with a lower stenosis rate, usually in the 3% to 5%
range.36 Use of totally absorbable suture is reported to
be associated with a lower incidence than use of per-
manent suture.37 Tension and ischemia will also increase
the incidence of this problem. The development of a
marginal ulcer should be promptly treated in its early
stages to allow resolution with the minimum amount
of residual scarring.
Marginal Ulcer at the Anastomosis
Consequence
Marginal ulcers develop at or just distal to the gastro-
jejunostomy. They cause epigastric pain, and may also
cause dyspepsia, nausea, food intolerance; in cases in
which the ulcer becomes severe and deep, bleeding and
gastrogastric stula may occur. Although medical treat-
ment may cure most ulcers, those associated with the
latter complications can cause life-threatening bleeding
and will need operative treatment. The incidence of
marginal ulcers after LRYGB is reported as between 2%
and 12%.38
Grade 25 complication
Repair
Marginal ulcers are diagnosed by using exible endos-
copy to visualize the gastrojejunostomy anastomotic
19 LAPAROSCOPIC GASTRIC BYPASS 217
area. Upper gastrointestinal series have a sensitivity
that is too low to be reliable. Persistent epigastric pain
after LRYGB is an indication for upper endoscopy. If
marginal ulcer is conrmed, the treatment is medical.
Triple antibiotic therapy effective against Helicobacter
pylori as well as a proton pump inhibitor (PPI) at
standard twice-daily dosing for 3 to 6 months then
once daily for an additional 6 months are indicated.
Repeat upper endoscopy is needed only if symptoms
persist or stenosis symptoms occur. Patients must avoid
smoking and intake of nonsteroidal anti-inammatory
drugs (NSAIDs), because these will prevent ulcer
healing or cause them, respectively. If a marginal ulcer
is large or deep on endoscopy, if symptoms have been
present for weeks, or if the ulcer fails to heal with stan-
dard therapy, an upper gastrointestinal contrast series
is indicated to rule out stulization of the ulcer from
the proximal gastric pouch to the lower stomach.38 In
addition, if there has been incomplete division of the
stomach such that a gastrogastric stula at any location
exists, the patient will need operative therapy to divide
the stula, resect the area of involved stomach, and
dilate the gastrojejunostomy. If the patient is severely
stenotic, the gastojejunostomy may need to be
revised.
Prevention
The prevention of marginal ulcer is improved by making
the proximal gastric pouch small to decrease potential
acid production, minimizing foreign material in per-
forming the anastomosis (such as reinforcing with per-
manent suture), treating patients with documented H.
pylori infection preoperatively to eradicate the organ-
ism,30 and ensuring complete division and separation
of the proximal gastric pouch from the lower stomach.
In addition, patients complaining of persistent epigas-
tric pain should be aggressively endoscoped to rule
out this problem, and treated early if the condition
is present. It must be stressed to patients that they
must stop smoking and they must refrain from ingest-
ing NSAIDs. Nonessential steroid usage should be
eliminated.
Closure of the Remaining Mesenteric Defects
Internal Hernia via the Colonic
Mesentery Opening
Consequence
If a retrocolic passage of the Roux-en-Y limb has been
used for LRYGB, the mesenteric defect in the trans-
verse colon mesentery must be closed to prevent post-
operative herniation. If it is not, herniation of another
loop of bowel adjacent to the Roux-en-Y limb into the
retrogastric space or herniation of the Roux-en-Y limb
itself to form an accordion-like mass of bowel behind
the stomach will result in postoperative bowel obstruc-
 218 SECTION III: GASTROINTESTINAL SURGERY
tion with potential for bowel ischemia and necrosis.
Vomiting, dehydration, electrolyte imbalances, tissue
necrosis with perforation and peritonitis, and death
may potentially occur.
Grade 15 complication
Repair
Bowel obstruction after LRYGB is a surgical problem.
Conservative therapy is inappropriate and dangerous
because of the high incidence of closed-loop obstruc-
tion and internal hernia.39 Because adhesion formation
is low after LRYGB, bowel obstruction is most likely
to be from an internal hernia of some type. Diagnosis
is by symptoms and computed tomography scan. Plain
lms may be suggestive if air-uid levels are seen in the
left upper quadrant behind the stomach. Computed
tomography scan may be diagnostic if it demonstrates
loops of small bowel behind the stomach. Operative
therapy is indicated. We have usually been able to use
a laparoscopic approach. If the Roux-en-Y limb itself
has been herniated behind the stomach, careful reduc-
tion, with or without enlargement of the mesenteric
opening as needed, is performed. When completely
reduced, the Roux-en-Y limb is resutured to both the
mesentery and the adjacent ligament of Treitz with
permanent suture. The bowel must obviously appear
healthy and without any areas of suspected necrosis
after reduction. If another loop of bowel has passed
into the lesser sac adjacent to the Roux-en-Y limb, it is
reduced and inspected. If viable, resuturing the Roux-
en-Y limb to the mesentery is all that is needed. If the
bowel is not viable, resection and reanastomosis are
indicated.
Prevention
The incidence of this problem is zero when the antecolic
passage of the Roux-en-Y limb is performed. When
the retrocolic passage of the Roux-en-Y limb is per-
formed, we have found a dramatic reduction in the
incidence of this complication with the use of perma-
nent suture to stitch the side of the Roux-en-Y limb to
the patients right as it passes through the colon mes-
entery to the biliopancreatic limb just distal to the
ligament of Treitz. Two sutures placed approximately
1.5 cm apart create a xed segment of the two loops
of bowel. The uppermost suture used for this joining
of the two bowel segments also includes two bites of
the colon mesentery, one at 1 oclock and another at
10 oclock on the mesenteric opening (Fig. 197). This
effectively closes the excess mesenteric space around
the Roux-en-Y limb, with the exception of the side of
the limb on the patients left. That side is then sutured
to the transverse colon mesentery using at least one
additional permanent suture in the 3 oclock position.
Using this triple stitch technique, we have observed
a herniation rate of all types involving the colon mes-
entery defect of approximately 1%.
Figure 197 Creating the triple-stitch. The suture is being
placed in the mesentery after it was rst placed in the bowel, just
before tying.
Petersens Space Hernia
Consequence
Herniation of the small bowel underneath the mesen-
tery of the Roux-en-Y limb after gastric bypass has been
termed Petersens hernia. This complication may occur
after any Roux-en-Y limb operation. If it occurs, the
symptoms may be minimal if the space is large and the
bowel can freely pass back and forth beneath the mes-
entery. However, if the space is small, herniation of a
signicant portion of the bowel will result in its entrap-
ment under the mesentery, with potential ischemia to
the entrapped bowel as well as, potentially, the Roux-
en-Y limb. Bowel obstruction symptoms, followed by
sequelae of bowel ischemia and necrosis, will follow if
operative treatment is delayed and the problem not
promptly treated. Recently, centers that perform small
bowel transplantation have seen a number of referrals
for patients who had loss most of the small intestine
after gastric bypass owing to this complication. Death
has also been reported.40
Grade 15 complication
Repair
Recognition of the problem is the rst and foremost
issue. Most bariatric surgeons will quickly appreciate
this possible problem in a patient after LRYGB who
presents with a clinical and radiographic picture of
small bowel obstruction. The problem is that a bariat-
ric surgeon is often not the person who initially treats
and evaluates such patients. Well-intentioned but igno-
rant general surgeons may often hospitalize the patient,
place a nasogastric tube, and give intravenous uids
the accepted initial treatment for adhesive postopera-
tive small bowel obstruction. However, after LRYGB,
adhesive obstruction is much less likely than internal
herniation and closed-loop obstruction. Therefore, the
treatment for any patient after LRYGB who presents
with a clinical and radiographic picture consistent with
small bowel obstruction is operative. Emergent lapa-

rotomy or laparoscopy is indicated, based on the sur-
geons talents and the patients bowel distention.
Reduction of any internal hernias is necessary. Often,
the identication of which piece of bowel is which
becomes very confusing. It is recommended that the
terminal ileum at the ileocecal valve be positively iden-
tied, then the ileum be traced retrograde to the
jejunum and then to the area of the enteroenterostomy.
Petersens hernia will be evident because some of this
distal bowel will be herniated under the mesentery of
the Roux-en-Y limb. Decompressing and reversing any
such volvulus and herniation are indicated, after which
the bowel must be assessed for viability. If no ischemia
is present, the Petersen defect is closed. If a retrocolic
Roux-en-Y limb is present, the limb can be sutured to
the ligament of Treitz (see previous section). If an
antecolic Roux-en-Y limb is present, the defect between
the base of the Roux-en-Y limb mesentery and the
transverse colon mesentery must be closed. This is a
very difcult technical procedure, and one of the con-
tributing reasons we prefer the retrocolic approach to
Roux-en-Y limb passage. Use of an omental patch into
the space can be considered if the defect is large. If the
reduced bowel is necrotic in any area, resection and
reanastomosis are indicated. Patients who have had
bowel necrosis from such an obstruction may be
extremely ill owing to the consequences of the bowel
ischemia; multiorgan system failure must be anticipated
and all measures taken to combat it.
Prevention
The closure of Petersens space is always indicated
after retrocolic LRYGB. Some surgeons who perform
antecolic LRYGB do not advocate closure of this space,
but accumulating case reports of bowel loss from her-
niation through this space strongly suggest this defect
should always be closed.41 Important to the prevention
of bowel ischemia is the prompt diagnosis and opera-
tive treatment of any patient who presents with a picture
of bowel obstruction after LRYGB.
Stenosis of the Roux-en-Y Limb at the Mesentery
Consequence
This complication is rare and is a result of either chronic
obstruction at the Roux-en-Y limb mesentery (described
previously under Roux-en-Y Limb Obstruction at the
Colonic Mesentery) or chronic ischemia of the bowel
from tight scarring in this area or excess tension and
ischemia on the Roux-en-Y limb mesentery. The con-
sequence is a stenotic area of bowel that, if symptom-
atic, is usually not amenable to endoscopic dilation but
requires operative resection and reanastomosis.
Grade 14 complication
Repair
This complication is rare. However, if it occurs, it will
present with obstructive symptoms similar to those of
19 LAPAROSCOPIC GASTRIC BYPASS 219
gastrojejunostomy stenosis. The same sequelae as that
complication (described in the section on Stenosis of
the Anastomosis, under Gastrojejunostomy, previ-
ously) may occur. Treatment is similar in terms of initial
resuscitation with attention to thiamine replacement
followed by intravascular rehydration. Nutritional status
must be addressed. Upper gastrointestinal series will
conrm the diagnosis, and reoperation to resect the
stenotic section of bowel is usually indicated. Dilation
may on occasion be successful.
Prevention
This problem is rare and can be prevented by avoiding
excess tension on the Roux-en-Y limb, as well as avoid-
ing excess tightness and scarring of the mesenteric
closure around the Roux-en-Y limb by using an inter-
rupted and not a continuous running permanent suture
for mesenteric closure.
Hemorrhage from the Mesentery
Consequence
Rarely, suturing the Roux-en-Y limb to the transverse
colon mesentery can be met with bleeding from the
transverse colon mesentery. This is usually easily
arrested. The colon is rarely in danger of ischemia
because of the collateral circulation that exists within
the upper portions of the mesentery.
Grade 1/2 complication
Repair
The hemorrhage is controlled with placement of addi-
tional interrupted sutures in the area of the bleeding of
the mesentery, with care being taken not to suture too
high on the mesentery and injure the collateral crossing
vessels of the colon.
Prevention
This complication is prevented by taking care to
avoid visible vessels in the transverse colon mesentery
when sutures are placed to close the mesenteric
defect.
Hematoma of the Roux-en-Y Limb
Consequence
Suturing the mesenteric defect closed as described
previously (under Closure of the Mesenteric Defect)
can involve a hematoma of the Roux-en-Y limb or the
biliopancreatic limb. Because the biliopancreatic limb
must allow the passage of only bile and pancreatic
juice, this hematoma is inconsequential. However, if
a larger hematoma were to result in the wall of the
Roux-en-Y limb, a partial bowel obstruction could
potentially occur. However, this complication is
exceedingly rare.
Grade 1/2 complication
 220 SECTION III: GASTROINTESTINAL SURGERY
Repair
Compression to limit the size of the hematoma is all
that can be done intraoperatively. Conservative therapy
postoperatively until the hematoma resolves, with the
retention of a liquid diet only for a longer than usual
period of time, is usually all that is needed.
Prevention
This complication is prevented by avoiding an exces-
sively large bite of the Roux-en-Y limb when closing
the mesenteric defect.
Closure of the Port Sites
Richters Hernia
Consequence
Failure to close the port sites, especially those 10 mm
and larger, is associated with a very low but denite
possibility of Richters hernia, in which a loop of small
intestine becomes partially incarcerated into the port
site opening. Intestinal obstruction may occur. The
incarcerated portion of the bowel may become isch-
emic. Perforation and peritonitis with its sequelae could
develop. This process can be seen with complete her-
niation of the bowel into an abdominal wall hernia
defect as well.42
Grade 35 complication
Repair
The problem must rst be recognized. Unexplained
bowel obstruction symptoms, especially within the rst
few days after surgery and with a more distal bowel
location as the obstruction site, should make one
think of this potential complication. Diagnosis is by
computed tomography scan and index of suspicion. If
the scan is not conrmatory and symptoms persist,
diagnostic laparoscopy is denitive. Treatment is then
based on bowel condition. Resection of any ischemic
Hemorrhage from/Hematoma
bowel is indicated. Repair of the port site hernia defect
of the Abdominal Wall
is also indicated.
Prevention
Closure of all port sites of 10 mm or larger should be
performed at the conclusion of all LRYGB procedures
in order to best prevent this complication. Data from
bladeless trocars suggest that perhaps these trocars do
not leave a large enough hernia defect to need closure.43
However, closure is still the best prevention.
Wound Infection
Consequence
The incidence of wound infection after LRYGB is con-
siderably less than that after open surgery. Comparisons
between the two approaches have shown a decrease of
from approximately 7% to a 1 to 2% incidence of wound
infections in open versus laparoscopic approaches.23
The severity of the laparoscopic wound infections is
usually minor as well owing to their size. Our experi-
ence with over 1000 LRYGBs is that we have seen only
1 port site wound infection that went on to develop an
abdominal wall fascial infection and loss of some tissue
of the abdominal wall. Most infections are supercial
and treated as outpatient problems.
Grade 13 complication
Repair
Treatment of port site wound infections is a combina-
tion of local treatment involving opening the wound
and draining and dbriding any nonviable tissue at the
site. Packing and wound care are then indicated. Oral
antibiotics are sufcient in most instances, and culture
is appropriate if purulence is present to conrm antibi-
otic sensitivity. Rarely does inpatient admission and
intravenous antibiotics or operative therapy for tissue
dbridement because of deep-seated abdominal wall
infection occur. However, these measures may be
needed if standard outpatient wound care and oral
antibiotics do not reverse the infectious process.
Prevention
Use of appropriate sterile technique, avoiding wound
contamination by not removing any contaminated
tissue through the port site without placing it in a bag,
gentle technique of wound closure to avoid tissue
injury, hemostasis at the wound site to prevent hema-
toma, and appropriate use of immediately preoperative
parenteral broad-spectrum antibiotics with appropriate
intraoperative redosing as indicated are the measures
that will, if used routinely, limit the incidence of wound
infections. Appropriate early wound drainage, local
care, and antibiotics with careful follow-up for treat-
ment effectiveness will minimize the likelihood of a
more serious wound infection developing.
Consequence
Closure of the port sites may be complicated by injury
to abdominal wall vessels that produce a hematoma or
hemorrhage from the port site. The consequences are
identical to those of hematoma and hemorrhage that
may occur at the start of operation with trocar inser-
tion. Intraoperative measures can usually limit the
problem to a small hematoma or amount of blood loss.
Unrecognized bleeding that occurs slowly postopera-
tively may accumulate to form a large and painful post-
operative hematoma of the abdominal wall, usually
within the rectus sheath. Treatment is usually nonop-
erative, and the hematoma absorbs over 6 to 8 weeks.
Rarely, hemorrhage or hematoma immediately after
surgery can require reoperation.
Grade 13 complication

Repair
Intraoperative treatment is the use of sutures passed
with a suture passer through the abdominal wall, as
described previously for hemorrhage following trocar
placement (under Creation of a Pneumoperitoneum).
Two well-placed sutures at right angles to each other
will usually arrest the hemorrhage or hematoma
formation.
Prevention
Prevention of this problem is highly likely if the suture
used to close the trocar sites is passed through the
abdominal wall at the 12 and 6 oclock locations of
the wound. This minimizes the likelihood of injuring
the epigastric vessels, if the port is near them.
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23. Schirmer BD. Morbid obesity. In Townsend CM (ed):
Sabistons Textbook of Surgery. The Biological Basis of
Modern Surgical Practice, 17th ed. Philadelphia: Elsevier
Saunders, 2004; pp 357400.
24. Blachar A, Federle MP, Pealer KM, et al. Gastrointestinal
complications of laparoscopic Roux-en-Y gastric bypass
surgery: clinical and imaging ndings. Radiology
2002;223:625632.
25. Omundsen M, Babor R, Johnston P. Outcomes after
oesophagogastrectomy for carcinoma of the esophagus.
Aust N Z J Surg 2007;77:3739.
26. Hwang RF, Swartz DE, Felix EL. Causes of small bowel
obstruction after laparoscopic gastric bypass. Surg Endosc
2004;18:16311635.
27. DeMaria EG, Sugerman HJ, Kellum JM, et al. Results of
281 consecutive total laparoscopic Roux-en-Y gastric
bypasses to treat morbid obesity. Ann Surg 2002;235:
640647.
28. Higa K. Laparoscopic Roux-en-Y gastric bypass: hand-sewn
gastrojejunostomy technique. In Buchwald H, Cowan
GSM, Pories WJ (eds), Surgical Management of Obesity.
Philadelphia: Saunders Elsevier, 2007; pp 214222.
29. Salinas A, Baptista A, Santiago E, et al. Self-expandable
metal stents to treat gastric leaks. Surg Obes Relat Dis
2006;2:570572.
30. Kriwanek S, Ott N, Ali-Abdullah S, et al. Treatment of
gastro-jejunal leakage and stulization after gastric bypass
with coated self-expanding stents. Obes Surg 2006;16:
16691674.
 222 SECTION III: GASTROINTESTINAL SURGERY
31. Schirmer B, Erenoglu C, Miller A. Flexible endoscopy in
the management of patients undergoing Roux-en-Y gastric
bypass. Obes Surg 2002;12:634648.
32. Salas-Salvado J, Garcia-Lorda P, Cuatrecasas G, et al.
Wernickes syndrome after bariatric surgery. Clin Nutr
2000;19:371373.
33. Gonzalez R, Lin E, Venkatesh KR, et al. Gastrojejunos-
tomy during laparoscopic gastric bypass: analysis of 3 tech-
niques. Arch Surg 2003;138:181184.
34. Lee SK, Dix J, Miller MS, et al. The inuence of a
laparoscopic approach for the performance of Roux-en-Y
gastric bypass on surgical outcomes at a university
teaching hospital during the past decade. Surg Obes Relat
Dis 2006;2:289290.
35. Nguyen NT, Stevens CM, Wolfe BM. Incidence and
outcome of anastomotic stricture after laparoscopic gastric
bypass. J Gastrointest Surg 2003;7:9971003.
36. Higa KD, Boone KB. Laparoscopic Roux-en-Y gastric
bypass for morbid obesity: technique and preliminary
results of our rst 400 patients. Arch Surg 2000;135:
10291034.
37. Capella JF, Capella RF. Gastro-gastric stulas and
marginal ulcers in gastric bypass procedures for weight
reduction. Obes Surg 1999;9:2228.
38. Schirmer BD. Strictures and marginal ulcers in bariatric
surgery. In Buchwald H, Cowan GSM, Pories WJ (eds):
Surgical Management of Obesity. Philadelphia, Saunders
Elsevier, 2007; pp 297303.
39. Higa KD, Ho T, Boone KB. Internal hernias after
laparoscopic Roux-en-Y gastric bypass: incidence,
treatment and prevention. Obes Surg 2003;13:350
354.
40. Mason EE, Renquist KE, Huang YH, et al. Causes of 30-
day bariatric surgery mortality: with emphasis on bypass
obstruction. Obes Surg 2007;17:914.
41. Paroz A, Calmes JM, Giusti V, Suter M. Internal hernia
after laparoscopic Roux-en-Y gastric bypass for morbid
obesity: a continuous challenge in bariatric surgery. Obes
Surg 2006;16:14821487.
42. Sukeik M, Alkari B, Ammori BJ. Abdominal wall hernia
during laparoscopic gastric bypass: q serious consideration.
Obes Surg 2007;17:839842.
43. Rosenthal RJ, Szomstein S, Kennedy CI, Zundel N.
Direct visual insertion of primary trocar and avoidance of
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Surg Endosc 2007;21:124128.
20
Gastrectomy with Reconstruction
Aimee M. Crago, MD, PhD, Gitonga Munene, MD,
and Stephen R. T. Evans, MD
INTRODUCTION
As the incidence of gastric ulcer disease has decreased and
medical management of the disorder has improved, partial
and complete resection of the stomach is most commonly
performed for neoplastic processes and is described in this
chapter predominantly as it pertains to this pathology.
Although wedge resection may be adequate for gastroin-
testinal stromal tumors and small polyps, anatomic resec-
tion is essential for malignant growths. Preoperative
preparation and staging should be carefully performed
because morbidity related to gastrectomy remains as
high as 21% to 33% and mortality is about 6% to 9%.14
Meticulous surgical technique, thorough knowledge of
anatomy, and experience are all essential components in
minimizing operative morbidity and mortality. Choice of
procedure depends on the underlying disease process,
with antrectomy indicated as a portion of therapy in gastric
ulcer disease and in distal tumors. Proximal gastrectomy
is appropriate for gastroesophageal junction cancers (dis-
cussed in Section XI, Chapter 70, Esophageal Surgery),
and total gastrectomy is essential for diffuse bleeding from
stress gastritis, in many lesser curve tumors, and in large
masses inadequately treated by a lesser procedure. Stan-
dard therapy for gastric cancer mandates that a 6-cm
margin be achieved and lymph node resection be per-
formed for adequate cancer staging.5
INDICATIONS
Gastric cancer
Complicated gastric ulcer disease
Gastric ulcer disease refractory to medical
management
OPERATIVE STEPS
Step 1 Patient, provider, and facility selection
Step 2 Anesthetic management
Step 3 Incision and exploration
Step 4 Entrance to the lesser sac
Step 5 Duodenal or gastric transection and division of
right vessels
Kocher maneuver
Step 6 Ligation of left gastroepiploic and short gastric
vessels
Step 7 Division of the proximal specimen
In total gastrectomy
In distal or subtotal gastrectomy
Step 8 Ligation of left gastric vessels in total
gastrectomy
Step 9 Lymphadenectomy
Step 10 Reconstruction
Billroth I reconstruction
Billroth II reconstruction
Roux-en-Y gastrojejunostomy
Roux-en-Y esophagojejunostomy
PREOPERATIVE CONSIDERATIONS
Patient, Provider, and Facility Selection
As previously noted, the rate of morbidity associated with
gastrectomy makes it essential that meticulous preopera-
tive preparation be made. Guidelines such as those
described in Section I, Chapter 4, Preoperative Pitfalls,
should be followed to ensure that patients with locore-
gional disease, who are considered candidates for resec-
tion, are medically optimized prior to surgery. An aspect
of preoperative preparation unique to the gastrectomy
and other complex procedures is selection of hospital
facilities. Hospital volume is an important factor in patient
outcome after gastrectomy, with mortality being 8.7% in
very high volume centers and 13% in centers in which
the procedure is rarely performed. Very high volume
centers were dened in these series as those performing
21 or more cases each year. This concept is also reected
in studies comparing outcomes in patients treated at
National Cancer Institutedesignated cancer centers
versus other institutions, with patients faring better at the
specialty facilities.1,6
Preoperative evaluation should also address the extent
of disease in patients with gastric cancer. This prevents
unnecessary procedures and maximizes the surgeons
 224 SECTION III: GASTROINTESTINAL SURGERY
preparedness to perform the procedure. Initial staging
typically begins with a computed tomography (CT) scan
of the abdomen, pelvis, and often, chest. CT can identify
metastatic disease in 66% to 77% of patients when used in
conjunction with endoscopic ultrasound (EUS).7,8 Preop-
erative laparoscopy may identify an additional 23% to 37%
of patients with M1 disease because CT fails to identify
peritoneal implants and liver metastases less than 5 mm in
diameter. Its use has been integrated in the National
Cancer Center Networks staging guidelines for gastric
cancer, although its benet may be limited to those
patients with gastroesophageal junction tumors and
tumors involving the whole stomach.9,10
Anesthetic Management
Section I, Chapter 4, Preoperative Pitfalls, addressing pre-
operative work-up of patients, also described the contribu-
tion of regional anesthetic techniques in minimizing
morbidity and mortality after major abdominal procedures
such as the gastrectomy. Epidural placement may result in
decreased narcotic requirements and improved pulmonary
toilet.
OPERATIVE PROCEDURE: TOTAL/
PROXIMAL GASTRECTOMY
Positioning, Incision, and Exploration with
Entrance into the Lesser Sac
The patient is positioned in a supine fashion on the oper-
ating table. A midline incision is made from the xiphoid
process to the umbilicus or lower abdomen, depending
on necessity. Superiorly, the xiphoid process can be
grasped and removed with electrocautery in order to reach
the region of the esophageal hiatus. A thorough explora-
tion of the abdominal cavity is made to conrm the
absence of peritoneal implants and liver metastases. After
exploration, the lesser sac is entered to begin mobilization
of the stomach.
Injury to the Middle Colic Vessels
Consequence
Injury to the middle colic artery in the setting of
insufcient collaterals can result in segmental ischemia
between the hepatic and the splenic exures. The trans-
verse colon should be repeatedly evaluated throughout
the remainder of the procedure. If collateralization to
this area of bowel is poor and signs of ischemia develop,
resection of the involved colon is essential to prevent
septic complications.
Grade 4 complication
Prevention
While the lesser sac is entered, the omentum can be
detached from the transverse colon in cancer proce-
Posterior layer
of greater omentum
Middle colic Posterior layer
vessels of transverse
Mesocolon
Figure 201 The stomach is retracted superiorly, demonstrating
the avascular plane between its posterior wall and the transverse
mesocolon. Dissection outside of this plane and into the mesocolon
can result in injury to the middle colic artery and vein. (Redrawn
from Fischer JE, Bland KI, Callery MP, et al. [eds]: Mastery of
Surgery, 5th ed. Philadelphia: Lippincott Williams & Wilkins,
2007.)
dures because it will always be resected with the speci-
men. An avascular plane provides the line of dissection
between the omentum and the transverse colon. This
plane continues superiorly along the transverse meso-
colon, and separation of the transverse mesocolon
and posterior stomach along this plane allows for supe-
rior retraction of the stomach. Dissection outside of
this plane can result in the injury to the middle colic
vessels and subsequent ischemia of the transverse colon
(Fig. 201).
Transection of the Distal Margin and Division
of the Right Gastric and Gastroepiploic Vessels
The distal margin of resection in total gastrectomy is just
past the pylorus. Transection of the duodenum is gener-
ally performed by staple technique (Fig. 202). The staple
line can be oversewn with a two-layer suture closure if the
duodenum is scarred or if there is evidence that the staple
line is poorly approximated. During this portion of a total
gastrectomy, the right gastric and gastroepiploic arteries
will be ligated where they give off branches to the distal
stomach, unlike in the proximal gastrectomy for gastro-
esophageal junction tumor, as described in Section XI,
Chapter 70, Esophageal Surgery, which requires preserva-
tion of these vessels. Mobilization of the duodenum to
allow transection may also involve complete Kocheriza-
tion of the duodenum to examine paraortic lymph nodes
for metastatic disease or clearing the rst portion of the
duodenum by incision of the hepatoduodenal ligament.
Section IV, Chapter 35, Pancreaticoduodenectomy,
describes duodenal dissection and the Kocher procedure
in the context of pancreaticoduodenectomy because these
 20 GASTRECTOMY WITH RECONSTRUCTION 225

Prevention
Modication of the standard duodenal stump closure
should be made in the context of a scarred duodenal
stump. Numerous methods to prevent leakage have
been described. Tube duodenostomy involves insertion
of a small feeding tube through the duodenal stump to
encourage formation of a controlled duodenocutane-
ous stula. Similarly, a feeding tube can be threaded
through the wall of the second portion of the duode-
num or through the wall of the jejunum downstream
A and into the lumen of the duodenal stump to provide
decompression of this portion of the afferent limb. Use
Tract of hepatic artery ( hidden by stomach)
of tube jejunostomy results in signicantly lower rates
Site of of persistant enterocutaneous stula after removal of
ligated the drainage tube than does use of the previously men-
right tioned tube duodenostomy.
gastric
artery The Bancroft closure is a procedure in which the
stomach is transected proximal to the pylorus. The mucosal
Stapler layer of the antral stump and the pylorus are dissected
away from the submucosa and removed. The submucosa
Surgeon and the muscularis layers of the prepyloric stomach are
hand
retracting then used to reinforce the closure of the duodenal stump
stomach (Fig. 203B). Alternatively, the Nissen closure can be
caudally used to reinforce a difcult stump. After the duodenum
B is transected, the open lumen is anastomosed to the
Site of ligated right Entrance to lesser sac capsule of the pancreas (see Fig. 203A). No level-one
gastroepiploic artery
Tract of pancreaticodualend artery
evidence directly compares these methods of duodenal
stump repair, but familiarity with all methods may provide
Figure 202 A, Transection of the duodenum occurs just past the surgeon with the ability to adapt to a given set of
the pylorus in distal or total gastrectomy. To isolate this portion obstacles.
of the duodenum, the right gastric and gastroepiploic arteries are
rst ligated and the liver is retracted superiorly. Care must be taken
to avoid the nearby portal structures. B, Major structures are Retained Gastric Antrum
outlined.
Complication
maneuvers must be performed carefully to prevent injury Recurrent peptic ulcer disease or gastritis can occur
to the portal structures. after distal gastrectomy and Billroth II reconstruction
when retained antrum tissue is continuously exposed
Duodenal Stump Blow-out to the unopposed bicarbonate secretion of the pancreas.
Duodenal stump blow-out occurs most often in the Grade 24 complication
context of severe scarring of the duodenum related to
chronic ulcer disease. Obstruction of the afferent limb has Repair
also been associated with the complication. Medical management via histamine receptor type-2 or
proton pump inhibitors can help over 50% of patients.
Complication Following the diagnosis of retained antrum, generally
Peritonitis and widespread sepsis can result from duo- performed by technetium scan, denitive repair may
denal stump blow-out. require resection of the duodenal stump or conversion
Grade 35 complication to a Billroth I reconstruction, in which gastric acid
would ow across the anastomosis to neutralize pan-
Repair creatic secretions.
Repair of ruptured duodenal stump cannot be treated
with conservative measures. Reexploration is required. Prevention
Attempts at primary repair with an omental patch can Antral tissue may extend 0.5 cm past the pylorus, and
be attempted, but wide drainage of the right upper therefore, transection of the duodenum past this point
quadrant and tube duodenostomy are also commonly can prevent this type of complication. Historically,
employed to create a controlled duodenocutaneous complete antral resection has been conrmed by visual-
stula that can subsequently be treated with bowel rest, izing the presence of Brunners glands, dening duo-
enteric drainage, and parenteral nutrition. denal tissue, at the distal margin of the specimen.
 226 SECTION III: GASTROINTESTINAL SURGERY
A closure. In this method of duode-
B Am J Surg 1991;162:523524.)
Division of Proximal Specimen in
Distal Gastrectomy
In distal gastrectomy, mobilization of the stomach
proceeds only to the level of the incisura and the third
branch of the right gastroepiploic artery. Dissection
should be performed between the stomach and the vas-
cular supply to preserve the right gastroepiploic artery.
Transection is generally performed using a surgical stapler
red from the incisura to the greater curvature. More
proximal transection may be necessary to obtain adequate
margins with adequate blood supply if the short gastric
vessels are left in place. Following proximal transection,
the surgeon proceeds to lymphadenectomy in total
gastrectomy.
Ligation of the Left Gastroepiploic and
Short Gastric Vessels
Dissection of the upper aspect of the greater curvature
requires transection of the short gastric arteries. Compli-
cations associated with ligation of the short gastric arteries
and the left gastroepiploic artery are covered in Section
III, Chapter 17, Laparoscopic Nissen Fundoplication. Of
note, surgeons should ensure that no undue traction is
placed on the spleen. This can result in splenic laceration
and hemorrhage, requiring repair of the splenic capsule or
a splenectomy.
Figure 203 A, Nissen
closure. This method, often
employed when the duodenum is
scarred to the pancreatic capsule,
is performed by rst transecting
the duodenum. The duodenal
stump is then anastomosed to
the pancreatic capsule or duode-
nal wall left in place on the
pancreatic capsule. B, Bancroft
nal stump closure, the stomach is
transected proximal to the
pylorus, where tissue is less
brotic. The gastric mucosa in
the duodenal stump is then dis-
sected away from the submucosa
into the duodenum. This is
secured with a pursestring suture,
and the seromuscular layer is
closed over the stump. (A and
B, Reproduced with permission
from Burch JM, Cox CL,
Feliciano DV, et al. Management
of the difcult duodenal stump.
Exposure and Isolation of the Gastroesophageal
Junction and the Left Gastric Vessels
with Transection of the Esophagus
During proximal or total gastrectomy, dissection of the
gastrohepatic ligament (lesser omentum) allows mobiliza-
tion of the lesser curve of the stomach. The left triangular
ligament can also be incised to provide better exposure to
the esophageal hiatus. As the stomach is retracted superi-
orly and to the patients right, the surgeon is able
to visualize the left gastric artery entering the stomach
just distal to the gastroesophageal junction (Fig. 204).
Complications encountered during this portion of the
procedure include damage to the hepatic veins (during
incision of the left triangular ligament), injury to a replaced
left hepatic artery (during transection of the hepatogastric
ligament), pneumothorax, and esophageal perforation.
These complications have been previously addressed in
Section III, Chapter 17, Laparoscopic Nissen Fundoplica-
tion. In a total gastrectomy, dissection of the gastro-
esophageal junction is followed by esophageal stapling. To
prevent retraction of the mobilized esophagus into the
chest, suture tags should be placed on the distal end of
the esophagus prior to transection.
Lymphadenectomy
The extent of lymphadenectomy required for gastric
adenocarcinoma remains controversial. Whereas Japanese
 20 GASTRECTOMY WITH RECONSTRUCTION 227

Table 201 Comparison of Billroth I and II

Reconstructions
Billroth I Billroth II

Potentially lower rates of Risk of marginal ulcer related

remnant carcinoma to retained antrum

Decreased rates of postprandial Recurrent cancer unlikely to

dumping occur adjacent to the
pancreatic head

Potential improvement in Facilitates lymphatic dissection

gastroesophageal junction Risk of afferent loop
function syndrome

Histologic changes related to Decreased rates of bile reux

gastritis in 80%90% of patients and gastritis

Retains normal physiologic Potentially lower rates of

passage of food into duodenum,
maintaining innate regulatory
pathways of bicarbonate and
pancreatic enzymes
anastomotic stricture owing
to anastomotic caliber
Anastomosis can be
performed in context of
extensive duodenal scarring

Figure 204 The left gastric artery branches from the celiac
trunk to enter the posterior aspect of the stomach. (Redrawn from
Fischer JE, Bland KI, Callery MP, et al. [eds.] Mastery of Surgery, 5th
ed. Philadelphia: Lippincott Williams & Wilkins, 2007.)
surgeons have shown signicant benet from extended
lymph node dissection in retrospective studies,1113 initial
reports from Western countries14,15 demonstrated no sur-
vival benet in patients with D2 (extended) versus D1
(limited) resection and found increased morbidity associ-
ated with more extensive procedures. Because of this,
recent meta-analyses have argued against routine perfor-
mance of the D2 lymphadenectomy during resection for
gastric cancer.16 High-volume centers can, however,
perform the procedure with low morbidity and mortality,
and because of faults associated with the trials addressing
this topic, many surgeons believe that recurrence rates and
survival in at least a subset of gastric cancer patients may
be positively affected by performing D2 resections. Com-
plications related to performing D2 resection have often
centered around splenectomy and distal pancreatectomy,
and one should refer to chapters on these topics when
planning to perform this procedure.
Reconstruction
Reconstruction after total or subtotal gastrectomy (greater
than two thirds of the stomach) is performed by complet-
ing an antecolic or retrocolic Roux-en-Y esophagogastrec-
tomy to prevent reux of bile into the esophagus. Partial
gastrectomies are most often reconstructed with a Billroth
II gastrojejunostomy or, less frequently, with a Billroth I
gastrojejunostomy, which has theoretical benet in certain
circumstances (Table 201). In the context of malignant
disease, Billroth I reconstruction is contraindicated,
because it will make subsequent proceduresnecessary
in the context of cancer recurrencesignicantly more
complicated.
Multiple methods of Billroth II reconstruction have
been reported with variation in the position of gastric
transection, variation in the placement of the gastrojeju-
nostomy along the line of gastric transection, and antecolic
versus retrocolic positioning of the gastrojejunostomy
dening the types of reconstruction (Fig. 205). The
Billroth I reconstruction has less variation, although
opinion has differed on the line of gastric transection and
placement of the gastrojejunostomy along this anastomo-
sis (Fig. 206). No clear data exist to support a preference
of Billroth I or Billroth II methods.
Anastomotic Leak
Rates of anastomotic leak are approximately 1% to 4% after
gastrectomy with gastroduodenostomy or gastrojejunos-
tomy and 5% to 15% in esophagogastrostomy with Roux-
en-Y reconstruction.17,18
Consequence
Intra-abdominal leak, peritonitis, sepsis, multiorgan
failure, and death. Early signs of leak include fever,
tachycardia, and worsening abdominal pain.
Grade 25 complication
Repair
Patients with anastomotic leak normally present with
evidence of systemic inammatory response and infec-
tion. Unexplained fevers and tachycardia can herald the
presence of this complication and should be investi-
gated by upper gastrointestinal series or CT scan.
Initiation of antibiotic therapy and nasogastric decom-
pression or percutaneous drainage can control many
leaks, as demonstrated in the literature describing anas-
tomotic leakage after gastric bypass surgery and in ret-
rospective analyses of gastrectomy patients.17,19,20 More
recently, the use of expandable, covered stents, placed
 228 SECTION III: GASTROINTESTINAL SURGERY

Billroth Wolfler Curvoisier Billroth

1851 1881 1883 1885

Heineke and Mikulicz Hofmeister Brown and Jaboulay Schoemaker

1886 1888 1892 1898

Roux Polya Balfour Von Haberer-1922

1898 1911 1917 Finney-1924

Figure 205 Methods of Billroth II reconstructions. (Redrawn from Shacklefords Surgery of the Alimentary Tract, Vol 2. Philadelphia,
WB Saunders, 1981.)

endoscopically, has been shown to result in sealing of Box 201 Risk Factors for Gastrointestinal
leaks at the site of both esophagojejunostomy and gas- Anastomotic Leak
trojejunostomy sites.21,22 Persistent evidence of inam- Malnutrition (albumin < 3.25)
mation, peritonitis, or worsening symptoms may require Weight loss
reoperation with abdominal washout and repair of the Alcohol abuse
anastomosis. Smoking
Intraoperative contamination
Long operative time (>46 hr)
Prevention
Multiple blood transfusions
A list of risk factors related to leakage after gastrointes-
Chronic obstructive pulmonary disease
tinal anastomosis is presented in Box 201. In our Peritonitis
practice, three of these risk factors led us to perform a Bowel obstruction
proximal diverting ostomy when a colocolostomy is Use of corticosteroids
performed. Such measures cannot be used to protect a Radiation
more proximal anastomosis such as that used for recon-
struction after a partial or total gastrectomy. Meticu- Based on references 18 and 5761.
lous technique remains the primary means of preventing
anastomotic leak. A gastrojejunostomy can be per- Special care should be taken when constructing an anas-
formed in one or two layers, but it is essential to take tomosis between the esophagus and the jejunum after
strong seromuscular bites to ensure integrity of the total gastrectomy. The anastomosis is particularly difcult
suture line. Rates of anastomotic leakage in a stapled because a layer of fatty tissue between the mucosa and the
anastomosis are not shown to be consistently different submucosa causes frequent retraction of the mucosa on
to those seen after a hand-sewn reconstruction. the cut end of the esophagus. It is essential that this layer
 20 GASTRECTOMY WITH RECONSTRUCTION 229

Billroth Billroth Kocher Kutscha-Lissberg v. Haberer

1881 1881 1890 1925 1920
A B C D E

v. Haberer, 1922 Winkelbauer Schoemaker Harkins, Nyhus

Finney, 1923 1927 1911 1960
F G H I
Figure 206 Billroth I reconstructions. (Reproduced with permission from Sieivert JR, Bumm R. Distal gastrectomy with Billroth I,
Billroth II or Roux-en-Y reconstruction. In Fischer JE, Bland KI, Callery MP, et al. [eds]: Mastery of Surgery, 5th ed. Philadelphia: Lippincott
Williams & Wilkins, 2007.)

be incorporated in a full-thickness stitch used to create the Repair

hand-sewn esophagojejunostomy in a Roux-en-Y recon-
struction after total gastrectomy. No benet of stapled
versus hand-sewn anastomosis has been consistently dem-
onstrated,23,24 and when choosing to create this anasto-
mosis with a circular stapler, a tight pursestring suture
through the esophageal wall and around the anvil helps
to ensure a sturdy anastomosis. After the stapler is red,
two complete rings of tissue, one obtained from each
limb, should be visualized. Incomplete tissue rings serve
to identify potential defects in construction.
A second technical point, uniquely applicable to the
Billroth I reconstruction, is the importance of addressing
the angle of sorrow or Jammerecke. This area denes
the junction of the gastroduodenostomy and the stapled
end of the stomach. A triple seromuscular suture placed
outside to in on the anterior wall of the stomach, inside
to out on the duodenum, and inside to out on the pos-
terior stomach can be used to secure this region.
Anastomotic Bleeding
Consequence
Hemorrhage and increased transfusion requirement.
Grade 2/3 complication
Anastomotic bleeding normally resolves spontaneously
postoperatively and can be treated with correction of
coagulopathy and limited transfusion. Upper endos-
copy can identify the site of bleeding and allow
for placement of clips or electrocautery. Rarely does
anastomotic bleeding require operative intervention
that involves gastrostomy and direct control of
hemorrhage.
Prevention
Although some surgeons consider rates of anastomotic
bleeding to be higher in stapled versus sutured anasto-
moses, large series in postgastrectomy patients do not
consistently show this to be the case.25 Regardless, a
two-layered hand-sewn anastomosis with one layer
being full-thickness with absorbable sutures results in
good hemostasis. Careful inspection and oversewing of
exposed staple lines can prevent some episodes of staple
line bleeding.
Postgastrectomy Syndromes
Numerous chronic complications related to gastrectomy
with reconstruction are discussed in references 26 to 28.
 230 SECTION III: GASTROINTESTINAL SURGERY
Afferent Loop Syndrome
Afferent loop syndrome is an uncommon complication
most often associated with Billroth II reconstruction in
which the afferent loop becomes obstructed owing to
stasis, adhesions, volvulus, or herniation.
Consequence
This complication can occur in the immediate postop-
erative period and present as unrelenting epigastric
pain, which reects a closed-loop obstruction. This may
result in duodenal stump dehiscence. Late presentation
of afferent loop syndrome is characterized by postpran-
dial fullness, nausea, and eventually, projectile, bilious
vomiting followed by relief of symptoms. Patients may
have jaundice owing to biliary outow obstruction,
pancreatitis, and postprandial epigastric mass. Deni-
tive diagnosis can be made by CT scan, upper gastro-
intestinal series, or endoscopy.
Grade 3 complication
Repair
Lysis or adhesions, reduction of internal hernia, short-
ening of the afferent loop, or bowel resection treating
the underlying cause of obstruction may correct the
problem. In emergent procedures, in which markedly
dilated loops of bowel are present, enteroenterostomy
between the afferent and the efferent loops of the gas-
trojejunostomy is an option. In the chronic syndrome,
shortening of the afferent loop (to 1015 cm) or con-
version to either Billroth I or Roux-en-Y gastrojejunos-
tomy will treat the condition.
Prevention
Afferent loop syndrome is associated with long afferent
loops (generally >30 cm in length), which can also
present with diarrhea, marginal ulcer, or malabsorption.
Antecolic reconstruction, antiperistaltic gastrojejunos-
tomy, and poor positioning of the gastrojejunostomy
along the greater curve of the stomach are also risk
factors in development of the syndrome and should be
considered when deciding the appropriate reconstruc-
tion for a given patient. Closure of the retroanastomotic
opening by tacking the anastomosis to the transverse
mesocolon can reduce the risk of retroanastomotic
hernia.
Efferent Loop Syndrome
Efferent loop syndrome is associated primarily with inter-
nal hernia but may also reect adhesive disease or jejuno-
gastric or jejunojejunal intussusceptions.
Consequence
Efferent loop syndrome presents in a manner similar to
small bowel obstruction with colicky abdominal pain,
nausea, and vomiting.
Grade 3 complication
Repair
Repair centers on correction of the underlying problem,
that is, hernia reduction and repair or lysis of adhesions.
Prevention
Proper closure of mesocolic defects and anchoring the
jejunum to the mesocolon are the most effective ways
of preventing internal herniation.
Anastomotic Stricture
Anastomotic stricture is seen in 1.5% to 13% of patients
after gastric resections.24,29 It can occur in the acute
postoperative period or many years after the initial opera-
tion. The etiology of anastomotic stricture or stenosis
can be anastomotic edema, extraluminal adhesion or
compression,30 cancer recurrence, or long-term brosis
and scarring. Chronic changes that result in strictures may
occur owing to ulceration, inadequate perfusion at the
anastomosis, or poor technique. The diagnostic work-up
of stricture should begin with a contrast study to evaluate
the etiology of the obstruction. Recurrent tumor at the
gastrojejunal anastomosis may be seen as plaquelike, ulcer-
ative, or polypoid lesions at or near the anastomosis on
upper gastrointestinal series. In esophagogastric anasto-
mosis, strictures resulting from anastomotic technique
typically appear as short, ringlike areas of narrowing,
whereas strictures from alkaline reux esophagitis appear
as long segments of smooth, tapered narrowing in the
distal esophagus. Eccentric anastomotic narrowing would
suggest recurrent tumor.31
Consequence
Patients present with dysphagia when related to esoph-
agogastrostomy stricture or with gastric outlet obstruc-
tion after gastric to small bowel anastomosis.
Grade 2/3 complication
Repair
After a contrast study is performed, an esophagogas-
troduodenoscopy should be performed as a diagnostic
and potentially therapeutic intervention. Benign anas-
tomotic strictures can be treated successfully with either
endoscopic balloon dilation or uoroscopy-guided
balloon dilation.32 For complete resolution of the stric-
ture, multiple dilations may have to be performed,
risking perforation.33 There have been several reports
of benign strictures being treated successfully with self-
expandable stents, but long-term data are still forth-
coming.34 The operation of choice for recalcitrant
stricture is anastomotic revision. If structuring is due
to recurrent tumors, the patient should be restaged,
and if resection is possible, surgical intervention should
include lymphadenectomy and completion gastrectomy
with reconstruction. In those patients with unresect-
able disease, palliation with metallic stents should be
considered.35
 20 GASTRECTOMY WITH RECONSTRUCTION
Prevention
Risk factors for anastomotic stricture include inade-
quate blood supply at the anastomosis, alkaline reux,
ulcer formation, anastomotic dehiscence, and smaller-
diameter stapled anastomosis. The surgeon should be
conscious of the blood supply preserved during resec-
tion, and the largest possible end-to-end anastomosis
stapler should be used to create the esophagogastrec-
tomy.36 These principles are particularly important in
laparoscopic resection because there have been reports
of increased anastomotic stricture (40%) after these
procedures compared with open gastrectomy.37
Roux Stasis Syndrome
Roux stasis syndrome presents in 30% of patients with
Roux-en-Y gastrojejunostomy.
Consequence
Early satiety, postprandial vomiting, and epigastric
pain.38 The etiology of this dysmotility is believed to
be related to disconnection of the transected Roux limb
from the duodenal pacemaker,39 but it may also be
related to gastric dysmotility or to anastomotic stricture.
Grade 2/3 complication
Repair
Patients are initially treated with promotility agents
such as metoclopramide or erythromycin.40 Endoscopy
may be useful for dilating anastomotic strictures. Failure
to improve with medical and endoscopic management
indicates the need for surgical intervention. Standard
therapy consists of subtotal gastrectomy with recon-
struction. This is essential if evidence of severe gastric
dysmotility is observed. More recently, conversion to
an uncut Roux-en-Y gastrojejunostomy, as described
later, has been shown to improve symptoms associated
with Roux stasis syndrome.41
Prevention
The Roux stasis syndrome can be prevented by per-
forming the uncut Roux-en-Y as initial reconstruction
(Fig. 207).38,41 Studies have also noted that longer
length of the Roux limb was associated with higher
rates of Roux syndrome, but as noted previously, this
must be balanced against the risk of afferent loop syn-
drome.
Bile Reux Gastritis
Bile reux gastritis is most commonly seen after Billroth
II reconstruction as a consequence of a defective pyloric
channel and results from exposure of the gastric mucosa
to bile, pancreatic secretions, and duodenal contents.
Consequence
Symptoms result in only 3% to 30% of patients with
endoscopic evidence of bile reux,42 and include
burning epigastric pain, bilious emesis, oral aversion,
231
Gastric enteric
stream
Bilious enteric
stream
Propagation of
enteric
pacesollar
potantlias
Staple line
Figure 207 Conversion to an uncut Roux-en-Y gastrojeju-
nostomy is believed to restore the physiologic ow of enteric
contents, improving dysmotility of the small bowel and relieving
symptoms related to Roux stasis syndrome. (From Collen JJ, Kelly
KA: Gastric motor physiology and pathophysiology. Surg Clin
North Am 1993;71:11451160.)
and weight loss. Pain is unrelieved by acid suppression
and is aggravated by both oral intake and the recum-
bent position. Bile reux gastritis is a diagnosis of
exclusion owing to the low specicity of endoscopic
ndings and histologic ndings (intestinalization of
gastric glands with inammation). Zollinger-Ellison
syndrome and other postgastrectomy syndromes should
be ruled out prior to operative repair aimed at correc-
tion of this condition.
Grade 24 complication
Repair
Medical management of bile reux gastritis includes
prokinetic agents, antispasmodic therapy, cholestyr-
amine, and dietary modication. The aim of reoperative
surgery in this setting is to divert duodenal contents
away from the gastric remnant and may be accom-
plished by any of several procedures:
Conversion to Roux-en-Y gastrojejunostomy with a
Roux limb of at least 40 cm is associated with symp-
tomatic relief in up to 85% of patients.42
Distal Braun enterostomy (see Fig. 205) has been
shown to improve symptoms of bile reux gastritis
in 53% of patients.43
The Henley procedure is a gastrojejunoduodenos-
tomy constructed with an interposition of a jejunal
segment approximately 40 cm in length between the
gastric remnant and the duodenum (Fig. 208).44
Symptomatic relief is seen in 70% of patients under-
going this procedure.
 232 SECTION III: GASTROINTESTINAL SURGERY
Figure 208 The Henley procedure creates a gastrojejunoduo-
denostomy with interposition of a 40-cm jejunal segment between
the gastric remnant and the duodenum. (From Aranow JS, Matthews
JB, Garcia-Aguilar J, et al. Isoperistaltic jejunal interposition for
intractable postgastrectomy alkaline reux gastritis. J Am Coll Surg
1995;180:648653.)
Biliary diversion using Roux-en-Y hepaticojejunos-
tomy can be performed by converting the gastric
anastomosis to a gastroduodenostomy and perform-
ing choledochojejunostomy.
Prevention
Rates of bile reux are lowest in the Roux-en-Y gastro-
jejunostomy, although the possibility of Roux stasis
syndrome should be weighed against this benet when
choosing reconstruction.
Dumping Syndrome
Dumping is a well-recognized complication of distal gas-
trectomy, occurring in as many as 25% of patients owing
to alteration in the pyloric outow mechanism.45,46
Consequence
Early dumping results from a hyperosomotic load deliv-
ered to the small bowel and causes abdominal cramping
and diarrhea. Late dumping is less common, is related
to hyperinsulinemia, and presents with hypoglycemic
symptoms that are relieved with carbohydrate
administration.
Grade 2/3 complication
Repair
Most patients will respond to medical management
of dumping syndrome. Low-carbohydrate, high-protein
meals and ber supplementation have been shown to
reduce dumping symptoms. If symptoms persist despite
dietary modication, the long-acting somatostatin ana-
logue, octreotide, can be administered with good effect
or the alpha-glucosidase inhibitor acarbose may prevent
absorption of the carbohydrate load, treating late
dumping symptoms.4749 Surgical therapy is rarely nec-
essary and historically centered on reconstruction of the
pylorus whether by direct repair after pyloromyotomy
or by creation of an antiperistaltic jejunal interposition
limb anastomosed between the stomach and the duo-
denum. Use of jejunal interposition has been largely
abandoned owing to high rates of postoperative
obstruction and gastric stasis. The most commonly
employed revision procedure to treat dumping syn-
drome is currently the Roux-en-Y gastrojejunostomy,
which results in near-complete symptom resolution in
86% of patients.50
Prevention
No clear measures are known to prevent dumping
when Billroth I or Billroth II reconstruction is planned,
and complications specic for Roux-en-Y gastrojeju-
nostomy should be weighed when choosing this as a
means to prevent dumping.
Delayed Gastric Emptying
Delayed gastric emptying occurs owing to either mechan-
ical outow obstruction or dysmotility related to altera-
tion in vagal innervation of the stomach or the gastric
pacemaker owing to surgery.
Consequence
Delayed gastric emptying can occur in the immediate
postoperative period, presenting as inability to tolerate
an oral diet. In the chronic setting, it is associated with
abdominal pain and bloating, nausea, vomiting, weight
loss, and malnutrition. Diagnosis is made by gastric
emptying studies that demonstrate delayed emptying
of solids. Endoscopy will show evidence of retained
food and, potentially, bezoar formation.
Grade 24 complication
Repair
Anastomotic strictures should be treated with endo-
scopic dilation, if possible, and adhesive disease should
be treated with reoperation. As in Roux stasis syn-
drome, promotility agents are the rst-line therapy
when no evidence of mechanical obstruction is found.
Metoclopramide, doperamide, and cisapride may
provide some symptomatic relief.40,51,52 In refractory
cases, patients may require a subtotal or complete
gastrectomy with Roux-en-Y reconstruction.53,54 Place-
 20 GASTRECTOMY WITH RECONSTRUCTION
ment of implantable pacemakers have been of some use
in severe gastroparesis after bariatric surgery and may
provide relief for some patients after gastrectomy.55
Prevention
Careful dissection around the esophageal hiatus to pre-
serve vagal innervation should minimize damage to the
autonomic innervation of the gastric remnant. Mainte-
nance of as much residual stomach as possible will
prevent inadvertent resection of the gastric pacer. In
patients undergoing Roux-en-Y reconstruction after
distal gastrectomy, higher rates of gastric stasis were
seen in patients who underwent more extensive lymph
node dissection.56
Risk factors associated with postoperative delayed gastric
emptying include diabetes and gastric outlet obstruction.
In patients with these conditions, consideration should
be given to placement of gastrostomy and feeding jeju-
nostomy tube placements at the time of operation. Pre-
operative nasogastric decompression may provide some
improvement in outcomes.27
Other Complications
Nutritional decits after gastrectomy can result in anemia,
neuropathy, and osteoporosis. Attention to adequate
vitamin replacement therapy must continue throughout
the patients lifespan and address malabsorption of iron,
vitamin B12, folate, vitamin D, and calcium. Stump carci-
noma is most common with Billroth II reconstruction,
occurring several decades after operation, and should be
considered in the differential diagnosis of patients present-
ing with vague abdominal complaints or weight loss. No
denitive recommendations for screening have been pub-
lished, but low threshold for endoscopy is appropriate.
Gastroesophageal reux disease is a common complication
of gastric surgery and may result from damage to the
lower esophageal sphincter, gastric dysmotility, or bile
reux. Medical management with metoclopramide or
domperidone and histamine receptor or proton pump
inhibitors should be attempted. Fundoplication (if possi-
ble) or revision surgery, as discussed previously and aimed
at addressing gastric dysmotility or bile reux, may be
required.
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21
Enterectomy
Reid B. Adams, MD

INTRODUCTION the concept that a clear set of factors predisposing to

anastomotic leak have not been delineated.
Enterectomy is a common procedure used primarily for
resection of small bowel or in combination with other
gastrointestinal procedures. Enterectomy also is used in INDICATIONS
conjunction with reconstructive procedures for replace-
ment of the gastrointestinal or urologic tract. This discus- Small bowel obstruction
sion focuses on primary enterectomy for treatment of Small bowel neoplasm
small bowel conditions. The complications discussed here Small bowel inammatory disease (e.g., Crohns disease)
are common to those procedures requiring small bowel Small bowel herniation with vascular compromise
resection for other reasons. Enterocutaneous stula
Enterectomy has been part of the abdominal surgeons Small bowel intussusception
repertoire for much of the history of surgery, yet the risks Mesenteric tumors when resection leads to small bowel
and complications associated with this procedure have ischemia
remained constant over its recent history. Whereas we Traumatic injury to the small bowel
may understand the pathophysiology and predisposing
factors for their development, complications persist and
all abdominal surgeons should be familiar with their devel- OPERATIVE STEPS
opment, consequences, repair, and prevention. This
chapter focuses on these issues related to enterectomy. Step 1 Incision
The reported leak rates for intestinal anastomosis Step 2 Evaluation of small bowel from ligament of
range from 1% to 8%.16 Specic leak rates for enterectomy Treitz to ileocecal valve
are more difcult to nd in the literature. One review Step 3 Identication of transection sites proximal and
reported a 1.1% leak rate in 798 patients undergoing distal to diseased segment
enterectomy.7 Step 4 Creation of anastomosis
The primary aspects necessary for construction of a Creating a mesenteric defect
successful anastomosis include careful approximation of Transection of bowel
well-vascularized bowel wall in a tension-free manner. Ligation and division of small bowel mesentery
Clearly, a technically inadequate anastomosis will lead Small bowel anastomosis
to anastomotic failure.8 However, despite a technically Inspection of anastomosis for bleeding
suitable anastomosis, complications such as anastomotic Closure of enterotomy resulting from small bowel
failure can occur. Signicant efforts have focused on anastomosis
understanding the nontechnical factors that contribute to Step 5 Assessment of anastomosis patency by palpation
anastomotic failure. Poor nutrition, hypoalbuminemia, Step 6 Suture closure of mesenteric defect
infection, smoking, diabetes, obesity, and many others Step 7 Closure of incision
have been implicated in various studies.14,7,911 Despite
extensive investigation, study results are conicting and
no consensus on predisposing factors has been reached.
OPERATIVE PROCEDURE
In Pickleman and coworkers review,7 the only factor pre-
dicting anastomotic leak after enterectomy was hyperten-
Incision
sion. How this contributed to anastomotic failure was
unclear from this study. No differences were seen in Injuries upon Entry into the Peritoneal Cavity
stapled versus sewn anastomoses or between different All grades of injuries can occur during this step. This is
types of anastomoses. Overall, their ndings reinforced primarily the case during reoperative surgery or during a
 238 SECTION III: GASTROINTESTINAL SURGERY

primary procedure when the bowel is grossly dilated.

Careful dissection and controlled entry into the peritoneal
cavity under these conditions are required to avoid entry
complications, as discussed in Section I, Chapters 6 and 7.

Evaluation of the Small Bowel

Missed Lesions
Many small bowel conditions (neoplasia, ischemia, stric-
tures, or obstruction) requiring enterectomy can be mul-
tifocal. Identication of all diseased segments is important
to facilitate complete treatment.
Consequence
Persistent neoplasm with development of obstruction
or metastasis. Residual ischemia leading to stricture,
obstruction, or perforation with peritonitis.
Grade 3/4/5 complication
Repair
Repeat operation for resection of residual tumor, isch-
emia, stricture, or obstruction.
Prevention
A thorough evaluation of the entire small bowel and
its mesentery is important to rule out additional lesions,
particularly if the procedure is being done for small
bowel neoplasm or ischemia. Identication of mass
lesions, strictures, or injuries is accomplished by
milking the bowel between the index and the middle
ngers (Fig. 211) and visually examining both sides Figure 211 Lesions within the bowel can be identied by
milking the bowel between the index and the middle ngers. This
of the bowel during this process. This allows identica-
allows small lesions to be palpated, preventing missed pathologic
tion of small lesions. Similarly, the mesentery in the ndings. In addition, enteric contents can be milked away from the
area of a small bowel neoplasm is palpated for lymph- site of an enterotomy, minimizing the risk of operative site con-
adenopathy and tumor involvement. tamination by enteric contents.
When assessing for ischemia, uorescein staining or
Doppler studies may aid in distinguishing viable from
ischemic segments when determining the extent of enter- transection site of the bowel is partly dictated by the
ectomy. One ampule of uorescein is given, and the small amount of mesenteric resection necessary to encompass
bowel is examined under a Wood lamp. Nonviable seg- the lymphatic drainage in the area of the neoplasm. Tran-
ments of bowel will be demarcated by this method. section for ischemic disease should be at sites that are well
When areas are indeterminate for ischemia at the initial vascularized. Transection for inammatory disease, such
laparotomy, a planned repeat laparotomy 24 hours later as Crohns disease, is done just outside the area of grossly
will allow assessment of the questionable areas of ischemia. involved bowel.
Additional enterectomy may be required at the second The consequences, repair, and prevention of this com-
operation. plication are similar to those in the prior section.

Identication of Transection Sites Proximal and Creation of the Anastomosis

Distal to the Diseased Segment
Missed or Recurrent Disease
The site chosen for transection of the small bowel is
dependent upon the disease process being treated. His-
torically, a distance of 5 to 10 cm away from the lesion
being resected has been advocated to ensure an adequate
resection margin when treating a neoplasm. However,
there does not appear to be literature providing solid
evidence to support a specic transection distance. The
Several techniques are described for enterectomy with
anastomosis. Currently, the most commonly practiced is
a stapled side-to-side, functional end-to-end anastomosis.
In some circumstances, this anastomosis is not technically
feasible and a sewn anastomosis is required. The stapled
anastomosis is used for illustrative purposes for this discus-
sion, because the general complications for enterectomy
with anastomosis are similar in both the stapled and the
sewn techniques.
 21 ENTERECTOMY 239

Figure 212 Backlighting the mesentery (transillumination)

allows identication of the vascular arcade (arrows). This permits Figure 213 Wound contamination is minimized by covering the
precise identication of the bowels edge (arrowhead) and the wound edges with a saline-moistened towel. This and the strategies
vessels (arrows). As a result, careful ligation can be done, preventing shown in Figures 211 and 214 limit enteric spillage and
injury to the bowel or the vascular arcade. contamination.

Injuries during Creation of a Mesenteric Defect

Injury to the small bowel or the adjacent mesentery can
occur during this step.
Consequence
Leakage of enteric contents, wound contamination,
and increased postoperative infection risk. Mesenteric
injury with bleeding, hematoma, or compromise of the
blood supply to the remaining small bowel. Any of
these injuries may lead to the unintended resection of
additional normal small bowel.
Grade 1/2 complication
Repair
The injured small bowel can be incorporated into the
stapled transection line or the resection specimen. The
mesenteric injury can be oversewn and/or incorpo-
rated into the resection specimen.
Figure 214 After the enteric contents are milked away from the
Prevention enterectomy site, noncrushing bowel clamps can be used to occlude
Transillumination of the mesentery (Fig. 212) will the lumen proximally and distally from the resection site, preventing
allow identication of the small mesenteric vessels and reux into the operative eld. The clamps are placed to the edges
the edge of the bowel, thereby avoiding these injuries. of the bowel, but not onto the adjacent mesentery (arrows).
Removing the lights from the operative eld followed
by direct light on the back side of the mesentery will tion of perioperative antibiotics, covering gram-negative
allow the surgeon to identify these structures. The bacilli and anaerobes, will minimize the risk of periopera-
avascular window is then marked with cautery or punc- tive infections.
tured with a tonsil clamp to mark its position.
Prevention of infection is facilitated by covering the
Difculties during Bowel Transection
wound with a moist towel to keep the enteric contents
Complications at this step usually are the result of device
from contaminating the edges (Fig. 213). The bowel
malfunction.
involved in the anastomosis also can be surrounded by
moist towels to contain any spillage of enteric contents. Consequence
Milking enteric contents away from the transection sites Spillage of enteric contents, intra-abdominal abscess
(see Fig. 211) and occluding the bowel proximally and formation, or wound infection. Additional loss of
distally with a noncrushing bowel clamp (Fig. 214) will healthy bowel can result if further intestinal resection is
minimize enteric contents in the enterectomy site. Place- required to repair the misre site. An inadequate staple
ment of the occluding clamp should be done in a fashion line can lead to anastomotic leak, as discussed later.
that does not include the mesentery. Finally, administra- Grade 1/2/3 complication
 240 SECTION III: GASTROINTESTINAL SURGERY
Repair
The site of malfunction typically results in an open
or injured piece of small intestine. Reapplication of the
stapler at an adjacent site of healthy bowel will treat
this complication.
Prevention
Stapler malfunctions are uncommon.8 Experienced sur-
geons frequently know whether the stapler has not
operated correctly. Occluding the bowel adjacent to
the stapler to prevent spillage of enteric contents can
be done while the stapler is removed and the staple line
inspected. If the bowel is not intact or is injured, the
stapler can be reapplied adjacent to the occluding bowel
clamp. Anticipating/recognizing a misring will mini-
mize opportunities for enteric spillage.
Stapler malfunctions can result from educational de-
ciencies or the introduction of new equipment or models.
Adequate staff and surgeon training regarding the use and
reloading of the devices will minimize these errors. Finally,
multiuse staplers should be red according to the manu-
facturers specications. Firing the stapler more times than
recommended may lead to malfunction.
Inadequate Ligation and Division of the Small
Bowel Mesentery
Consequence
Bleeding or hematoma formation. Imprecise ligation
can cause small bowel ischemia, leading to unnecessary
resection of healthy intestine. Unrecognized, inade-
quate ligation can result in immediate or delayed major
intra-abdominal hemorrhage.
Grade 1/3/4 complication
Repair
Bleeding sites can be transxed with a suture ligature
or reclamped and ligated to achieve hemostasis. Care
should be taken to prevent occlusion of adjacent major
vessels and subsequent ischemic injury. Expanding
hematomas can be treated with a suture ligature to
achieve hemostasis of a retracted mesenteric vessel.
Although rarely required, opening of the hematoma
may be necessary to ensure accurate and complete liga-
tion of the bleeding site.
Ligation resulting in ischemic intestine requires addi-
tional resection of intestine back to adequately perfused
bowel.
Delayed hemorrhage typically requires reoperation and
ligation of the bleeding site. This may result in intestinal
ischemia, requiring re-resection of the small intestine
including the site of the anastomosis. Alternatively, interven-
tional angiography may allow identication and emboliza-
tion of the bleeding site if it can be selectively cannulated.
Prevention
Transillumination of the mesentery (see Fig. 212) will
allow determination of the exact location of the mes-
enteric vessels. This ensures accurate and adequate liga-
tion. Occasionally, a fatty mesentery prevents accurate
location of the vessels or an adequate purchase for a
tie. A suture ligature used in this instance will prevent
dislodgement of the tie. Good communication between
the surgeon and the assistant will prevent premature
removal of the clamp before the suture is secured.
Difculties during the Anastomosis
A number of complications can occur during this step as
a result of equipment malfunction or operator error.
Attention to the technical details of this and the following
steps will minimize complications during this part of the
procedure.
Consequences
Failure to accurately line up the proximal and distal
ends of the bowel can result in a distorted, torqued,
and dysfunctional anastomosis with a stricture or
obstruction. Stapler malfunction can occur, as described
previously. However, loss of this staple line results in a
much greater loss of healthy intestine because both the
proximal and the distal bowel ends will require resec-
tion back to healthy bowel. Alternatively, suture repair
of the injury may sufce. Perforation of the bowel with
the end of the stapler can occur if both limbs are not
adequately seen during stapler insertion. Again, this
will require repair or resection of healthy bowel.
Enteric spillage during this step can lead to infection,
as discussed previously.
Bleeding from the staple line can result in immediate
or delayed hemorrhage. Delayed hemorrhage can result
in obstruction at the anastomosis or disruption of the
anastomosis owing to distention, which can result in an
anastomotic leak.
An inadequate or disrupted staple line can lead to anas-
tomotic leak, as discussed later.
Grade 1/2/3/4/5 complication
Repair
Mechanical problems resulting in a strictured or
obstructed anastomosis may require resection of the
anastomosis and construction of a new one. Similar
treatment is used for stapler malfunctions that result in
an inadequate staple line or anastomosis.
Bleeding at the anastomosis can be treated with a trans-
xing suture.
Prevention
Careful approximation of the proximal and distal limbs
of the bowel involved in the anastomosis will prevent
misalignment complications (Fig. 215). A traction
suture placed at the cut ends of the bowel will help
ensure that the two pieces are pulled equally onto the
stapler jaws (Fig. 216). Rotation of the bowel so the
antimesenteric edges are in approximation will ensure
a technically precise anastomosis (Fig. 217). Adequate
inspection and palpation during stapler placement will
prevent perforation injuries (Fig. 218).
 21 ENTERECTOMY 241

A Enteric spillage can be prevented, as described

previously.
Opening of the stapler jaws completely, prior to remov-
ing the stapler, will prevent traction injuries, including
bleeding, once the stapler is red. Retraction of the edges
of the enterotomy and direct inspection of the staple line
will allow identication and oversewing of any bleeding
sites and will prevent delayed hemorrhage complications
(Fig. 219).

Failure at the Enterotomy Closure Site

Consequence
Strictured anastomosis. An inadequate staple line can
B lead to anastomotic leak, as discussed later.
Grade 1/2/3/4 complication
Repair
Reapplication of the stapler or oversewing of the
inadequately closed enterotomy. Narrowing/stricture
requires construction of a new anastomosis.
Prevention
Care to include the entire length of the enterotomy is
required to prevent this problem. At each corner of the
enterotomy, an Allis clamp is placed with one jaw into
the lumen of the anastomosis (Fig. 2110). The Allis
is partially closed while withdrawing the clamp, thereby
Figure 215 A, The proximal and distal ends of the bowel are
grabbing the mucosa to ensure that full-thickness bowel
aligned by traction sutures (arrowheads). Careful approximation is included in the enterotomy closure. This prevents
prevents misalignment complications, such as kinking or twisting of inadequate closure at the corners of the enterotomy.
the bowel limbs. B, To anastomose the proximal and distal bowel Alternatively, a suture through each corner of the anas-
limbs, an enterotomy is made in the antimesenteric border of each tomosis and a suture in the middle of the anastomosis,
limb. The proximal traction suture (not seen, behind the stapler) is all of which include the full thickness of the bowel, can
then used to pull the bowel ends up onto the stapler arms, bringing be used to hold the bowel edges in apposition to allow
them into appropriate alignment (arrows). precise closure. The staple lines are offset slightly from

B
Figure 216 A, The proximal traction sutures (arrows) help pull the bowel ends onto the stapler arms. This suture ensures that the
bowel ends are aligned (arrowheads). B, Inspection of the posterior part of the staple line ensures that the entire anastomosis is appropri-
ately aligned.
 242 SECTION III: GASTROINTESTINAL SURGERY

Figure 217 Once the stapler jaws are closed, proper alignment
of the bowel limbs includes the ends at the enterotomy sites (arrow-
heads) and the small bowel mesentery (arrow), which is held out
directly opposite (180) from the anastomosis. The surgeons
ngers are placed behind the bowel as shown to insure no other
structures are caught in the staple line.
Figure 218 A, The distal end of the staple line requires inspec-
tion as the stapler arms are inserted into the bowel lumen. This
prevents a through-and-through bowel injury from the tip of the
stapler (arrows) coming out the bowel wall. B, This is particularly
true when an anastomosis is done deep in the abdominal cavity and
the distal end of the anastomosis is difcult to see.

each other (see Fig. 2110) and the two edges of bowel
between the corner clamps are held in approximation
with additional Allis clamps (Fig. 2111).
Application of the linear non-cutting stapler just below
the Allis clamps will prevent narrowing of the anastomosis
and subsequent stricture formation (Fig. 2112).
A buttressing suture placed at the end of the staple line
will prevent tension at this portion of the anastomosis
(Fig. 2113).
Assessment of the patency of the anastomosis is done
by palpation of the lumen (Fig. 2114). In addition,
intraluminal air can be milked into the anastomosis to
distend it and ensure an airtight seal. Likewise, passage of
succus through the anastomosis ensures an adequate size
of the opening.
Figure 219 The staple line (arrow) can be inspected directly
Anastomotic Failure to ensure hemostasis. Bleeding along the staple line can be
Anastomotic disruption and leakage are dreaded and suture-ligated to prevent delayed anastomotic bleeding resulting in
potentially fatal complications of enterectomy. Although obstruction or disruption.

these fears are warranted, the incidence of anastomotic
failure for enterectomy is low, 1.1% in one series, resulting
in a mortality of 0.4%.7
Figure 2110 An Allis clamp is placed at each corner of the
enterotomy. One side of the clamp is placed into the lumen, par-
tially closing it and pulling outward to include the mucosa (arrows)
within the closed clamp. This insures that full-thickness bowel and
the entire corners are included in the enterotomy closure. The
initial (gastrointestinal anastomosis) staple lines are offset (arrow-
heads) during closure of the enterotomy to avoid multiple overlap-
ping staple lines.
Inadequate Closure or Injury during Closure of
the Mesenteric Defect
Figure 2111 Allis or Babcock clamps are used to approximate
the bowel edges to insure complete closure of the enterotomy
site.
Figure 2112 The linear non-cutting stapler is placed just
beneath the clamps, allowing complete closure of the enterotomy
without narrowing the anastomosis.
21 ENTERECTOMY 243
Consequence
Anastomotic leak, intra-abdominal abscess, enterocuta-
neous stula, peritonitis, and death.
Grade 2/3/4/5 complication
Repair
Contained leaks without generalized peritonitis can be
treated with supportive care, antibiotics, and percuta-
neous drainage. Failure of this treatment, a free leak or
generalized peritonitis requires laparotomy for repair.
In these circumstances, drainage alone is associated
with increased mortality. Repair of the anastomosis
can be done, but most authors favor construction of a
new anastomosis. Either way, a proximal diverting
ostomy is recommended by some authors as part of the
procedure.7
Prevention
All authors believe that attention to the technical details
during construction is critical. In addition, all adhere
to the primary tenets of this and any other anastomosis
that the minimum requirements for a successful
anastomosis are adequate approximation of well-
vascularized tissue in a tension-free manner. Despite a
technically excellent anastomosis, leaks still occur. As
noted earlier, although signicant efforts have been
devoted to detecting risk factors for anastomotic failure,
the results from these studies have been mixed and
variable. Consequently, no consistent risks have been
identied that might be optimized preoperatively to
minimize the nontechnical risks of anastomotic failure.
Consequence
Internal herniation, bleeding, hematoma, and anasto-
motic failure.
Grade 1/2/3/4/5 complication
Repair
Internal herniation requires laparotomy to reduce the
hernia. Ischemic injury may require resection and
reconstruction of the ischemic bowel. Injury typically
results in bleeding or hematoma, requiring suture liga-
tion of the bleeding site.
Prevention
When closing the mesenteric defect include small bites
of the peritoneum only (Fig. 2115). Deeper bites into
the mesenteric adipose tissue result in vascular injury.
Avoid placing sutures at sites where the sutures used to
ligate the mesentery during mesenteric division are
present. Vessels extend to the edge of the mesentery at
these sites and are more easily injured with the super-
cial bites of the closing sutures. Inspection after
 244 SECTION III: GASTROINTESTINAL SURGERY
A B
Figure 2113 A, The corner of the staple line (arrow). B, A suture is placed adjacent to the linear staple line (arrow) to prevent
tension at this site. This is the buttressing suture.
Figure 2114 The lumen of the anastomosis (indicated by the
bracket) can be palpated between the thumb and the index nger
to ensure that it is patent.
closure insures adequate approximation to prevent sub-
sequent herniation.
Closure
Injury during Closure of the Incision
All grades of injury can occur at this step. Careful fascial
approximation will avoid these complications, as discussed
in Section I, Chapters 6 and 7.
Figure 2115 During closure of the mesenteric defect (edge
indicated by small arrowheads), small supercial bites of the periton-
eum (see the needle) are obtained to avoid injury to the mesenteric
vessels. Care is used to avoid the mesentery ligation sites (arrows),
where vessels come to the cut edge of the mesentery and, there-
fore, are easily injured.
Other Complications
Short Bowel Syndrome
Grade 4 complication
Although not a technical complication of enterectomy,
short bowel syndrome is a consequence of massive intes-
tinal resection. Symptoms can be avoided if more than
150 cm of small bowel remain intact. A minimum of

50 cm of small bowel in the absence of any colon is
required to allow adaptation.12,13 Jejunal resection is toler-
ated better than ileal resection, because the ileum adapts
better than the jejunum.13 Maintaining the ileocecal valve
and as much colon as possible also diminishes the onset
and severity of symptoms from massive enterectomy.
Finally, stricturoplasty and other techniques to maintain
length in patients with small bowel disease, such as Crohns
disease, will prevent short bowel syndrome in those
patients in whom even minimal resections may lead to
symptoms owing to their diseased bowel.
Nutritional Deciencies
Grade 1 complication
Resection of signicant ileum can lead to nutritional de-
ciencies, most notably vitamin B12. Patients with extensive
ileal resection should have B12 supplementation. Malab-
sorption of fat, fat-soluble vitamins, and bile salts also
occurs with extensive ileal resection. Fat malabsorption
may require supplementation for fat-soluble vitamins A,
D, and E.14 It also can lead to nephrolithiasis.15 Bile salt
malabsorption can lead to diarrhea and cholelithiasis.
Ileus
Grade 1 complication
A common feature of abdominal surgery, ileus prolongs
hospital stay and increases patient discomfort. Although
not unique to enterectomy, ileus may be decreased
by a number of interventions including the use of
thoracic epidural catheters, avoidance of systemic opioid
analgesics, administration of new pharmacologic agents,
and the use of laparoscopic techniques, all feasible in
enterectomy.16,17
In addition, the effects of postoperative ileus may
be minimized by a number of strategies. Numerous
studies demonstrate no benet in the routine use of
nasogastric tubes postoperatively.18 Likewise, early post-
operative feeding has become standard, because only 10%
to 20% of patients fail the early initiation of a diet.19
Together, these strategies minimize the effects of an ileus,
lessening patient discomfort and shortening the length
of stay.
Postoperative Bowel Obstruction
Grade 1/3/4 complication
Early or late bowel obstruction can occur after enterec-
tomy. Like an ileus, this is not a technical error in the
conduct of the operation, but a consequence of laparot-
omy. Early obstruction can mimic ileus, and distinguish-
ing the two may be difcult.20 Ileus usually resolves after
3 to 5 days. Lack of bowel activity or progressive disten-
tion after this time typically represents an early small
bowel obstruction. The risk of occurrence is reported to
be 0.7% at 4 weeks after operation,21 although Fazio and
associates22 reported that 30% of all bowel obstructions in
their series occurred within 30 days of the operation.
Resolution with conservative therapy occurs in approxi-
21 ENTERECTOMY 245
mately 90% of patients by 10 to 14 days. The risk of
strangulation obstruction is reported to be extremely
small, allowing prolonged conservative therapy in this
group of patients.
Late postoperative bowel obstruction most commonly
occurs as a result of adhesions. Up to 90% of patients will
develop adhesions postoperatively.23 However, a smaller
percentage, approximately 3% to 30%, will develop a small
bowel obstruction as a result of adhesions.22,2428 Whereas
signicant research has been devoted to minimizing post-
operative adhesions and subsequent bowel obstruction,
reliable means for doing so have been elusive. Recently,
adhesion-prevention products have proved successful in
decreasing the risk of adhesive small bowel obstruction
based on randomized, controlled trials.22
REFERENCES
1. Jex RK, van Heerden JA, Wolff BG, et al. Gastrointestinal
anastomoses. Factors affecting early complications. Ann
Surg 1987;206:138141.
2. Carty NJ, Keating J, Campbell J, et al. Prospective audit
of an extramucosal technique for intestinal anastomosis
[see comment]. Br J Surg 1991;78:14391441.
3. Golub R, Golub RW, Cantu R Jr, Stein HD. A multivari-
ate analysis of factors contributing to leakage of intestinal
anastomoses. J Am Coll Surg 1997;184:364372.
4. Max E, Sweeney WB, Bailey HR, et al. Results of 1,000
single-layer continuous polypropylene intestinal anastomo-
ses. Am J Surg 1991;162:461467.
5. Kaidar-Person O, Person B, Wexner SD. Complications
of construction and closure of temporary loop ileostomy.
J Am Coll Surg 2005;201:759773.
6. Hautmann RE, de Petriconi R, Gottfried HW, et al. The
ileal neobladder: complications and functional results in
363 patients after 11 years of followup. J Urol 1999;161:
422427; discussion 427428.
7. Pickleman J, Watson W, Cunningham J, et al. The failed
gastrointestinal anastomosis: an inevitable catastrophe?
J Am Coll Surg 1999;188:473482.
8. Baker RS, Foote J, Kemmeter P, et al. The science of
stapling and leaks. Obes Surg 2004;14:12901298.
9. Irvin TT, Goligher JC. Aetiology of disruption of
intestinal anastomoses. Br J Surg 1973;60:461464.
10. Pruett TL, Simmons RL. Failure of Gastrointestinal
Anastomosis. Chicago: Year Book Medical, 1984.
11. Resegotti A, Astegiano M, Farina EC, et al. Side-to-side
stapled anastomosis strongly reduces anastomotic leak
rates in Crohns disease surgery. Dis Colon Rectum
2005;48:464468.
12. Sax HC. Specic nutrients in intestinal failure: one size
ts no one. Gastroenterology 2006;130(2 suppl 1):
S91S92.
13. Tappenden KA. Mechanisms of enteral nutrientenhanced
intestinal adaptation. Gastroenterology 2006;130(2 suppl
1):S93S99.
14. Jeejeebhoy KN. Management of short bowel syndrome:
avoidance of total parenteral nutrition. Gastroenterology
2006;130(2 suppl 1):S60S66.
 246 SECTION III: GASTROINTESTINAL SURGERY
15. Buchman AL. Etiology and initial management of short
bowel syndrome. Gastroenterology 2006;130(2 Suppl 1):
S5-S15.
16. Saclarides TJ. Current choicesgood or badfor the
proactive management of postoperative ileus: a surgeons
view. J Perianesth Nurs 2006;21(2A suppl):S7S15.
17. Wolff BG, Michelassi F, Gerkin TM, et al. Alvimopan, a
novel, peripherally acting mu opioid antagonist: results of
a multicenter, randomized, double-blind, placebo-
controlled, phase III trial of major abdominal surgery and
postoperative ileus. Ann Surg 2004;240:728734;
discussion 734735.
18. Vermeulen H, Storm-Versloot MN, Busch OR, Ubbink
DT. Nasogastric intubation after abdominal surgery: a
meta-analysis of recent literature. Arch Surg 2006;141:
307314.
19. Behrns KE, Kircher AP, Galanko JA, et al. Prospective
randomized trial of early initiation and hospital discharge
on a liquid diet following elective intestinal surgery. J Gas-
trointest Surg 2000;4:217221.
20. Sajja SB, Schein M. Early postoperative small bowel
obstruction. Br J Surg 2004;91:683691.
21. Stewart RM, Page CP, Brender J, et al. The incidence and
risk of early postoperative small bowel obstruction. A
cohort study. Am J Surg 1987;154:643647.
22. Fazio VW, Cohen Z, Fleshman JW, et al. Reduction in
adhesive small-bowel obstruction by Sepralm adhesion
barrier after intestinal resection. Dis Colon Rectum 2006;
49:111.
23. Menzies D, Ellis H. Intestinal obstruction from adhe-
sionshow big is the problem? Ann R Coll Surg Engl
1990;72:6063.
24. Parker MC, Ellis H, Moran BJ, et al. Postoperative
adhesions: ten-year follow-up of 12,584 patients undergo-
ing lower abdominal surgery. Dis Colon Rectum 2001;44:
822829; discussion 829830.
25. Nieuwenhuijzen M, Reijnen MM, Kuijpers JH, van Goor
H. Small bowel obstruction after total or subtotal
colectomy: a 10-year retrospective review. Br J Surg 1998;
85:12421245.
26. Ellis H, Moran BJ, Thompson JN, et al. Adhesion-related
hospital readmissions after abdominal and pelvic surgery: a
retrospective cohort study.[see comment]. Lancet 1999;
353:14761480.
27. Beck DE, Opelka FG, Bailey HR, et al. Incidence of
small-bowel obstruction and adhesiolysis after open
colorectal and general surgery [erratum appears in Dis
Colon Rectum 1999;42:578]. Dis Colon Rectum 1999;
42:241248.
28. Matter I, Khalemsky L, Abrahamson J, et al. Does the
index operation inuence the course and outcome of
adhesive intestinal obstruction? Eur J Surg 1997;163:
767772.
22
Ileostomy
James FitzGerald, MD
INTRODUCTION
Proper construction of an ileostomy is a fundamental and
essential skill for all surgeons operating in the abdomen.
It can be performed either as a separate operation or as
a part of a larger procedure and can be created using a
traditional open incision or laparoscopic techniques.1
Depending upon the indication, an ileostomy may be
constructed in a variety of ways. Because both ends of the
small bowel are accessible on the surface of the skin, loop
ileostomies are generally easier to close and intended to
be temporary stomas. However, a recent study of patients
undergoing surgery for rectal cancer showed that approxi-
mately 19% of these temporary stomas will never be
reversed.2 End ileostomies may be either permanent or
temporary depending upon the remaining bowel anatomy,
but generally require a laparotomy to restore bowel con-
tinuity. An end-loop ileostomy is generally used when
there is difculty reaching through the abdominal wall
(Fig. 221).
Ileostomies have a signicant impact on the quality of
life of patients, with up to 80% experiencing some change
in their lifestyle after the creation of a stoma.3 The degree
of social impact appears to be related to the number of
stoma care problems.4 Regardless of the indication for the
procedure or the technique used, surgeons must adhere
to several basic principles in order to minimize postop-
erative stoma-related complications.
INDICATIONS
After surgical resection of the colon and rectum
Protection of a high-risk anastomosis
Temporary fecal diversion for perineal infections
OPERATIVE STEPS
Step 1 Site selection
Step 2 Selection and preparation of bowel segment
Step 3 Alignment of layers of abdominal wall
Step 4 Skin and subcutaneous tissue incision
Step 5 Anterior rectus sheath fascial incision
Step 6 Separation of rectus muscle bers
Step 7 Posterior rectus sheath fascial incision
Step 8 Passing bowel through abdominal wall
Step 9 Placing the bridge and maturing the stoma
OPERATIVE PROCEDURE
Site Selection
Poorly Fitting or Leaking Stoma Appliance
Consequence
Breakdown of the skin surrounding the ileostomy.
Approximately 28% of patients with an ileostomy would
prefer the stoma to be relocated, and the percentage is
higher in patients undergoing an emergency procedure
(37%) than in those undergoing elective surgery (23%).3
Thirty percent to 61% of patients experience excoria-
tion of the skin around the stoma, and 22% to 57% of
patients experience leakage46 (Fig. 222).
Grade 1 complication
Repair
Patient education and changing the type of appliance
may be effective. In extreme cases, laparotomy with
stoma relocation may be necessary.
Prevention
Ideally, the stoma should be placed through the rectus
muscle centered on a at area or on the crest of a fat
roll away from scars, creases, or bony prominences. The
site should be chosen prior to the operation after exam-
ining the patient in the supine and sitting positions.
Marking the patient preoperatively in the proper site
can signicantly reduce skin problems in the immediate
postoperative period.7
Selection of the Bowel Segment and
Preparation of the Bowel
High-Output Stoma
Consequence
Electrolyte imbalances or dehydration potentially
leading to acute renal failure. A prospective analysis of
 248 SECTION III: GASTROINTESTINAL SURGERY

Figure 221 An end-loop ileostomy. The mesentery to the

bowel is not divided, enabling the bowel to be brought through a
thick abdominal wall without the risk of ischemia. (Adapted from
Wu JS. Ileostomy. Oper Tech Gen Surg 2003;5:257263.)

60 patients undergoing restorative colectomy with a

defunctioning ileostomy showed that ileostomy output
peaked at postoperative day 4 and that the critical
period for acute dehydration was from 3 to 8 days
after the operation. During this time, ileostomy output
is increasing, but oral intake is still limited.8 Overall,
dehydration occurs in 5% to 20% of patients with
ileostomies.6,9 B
Grade 1 complication
Figure 222 The site for this ileostomy was not marked prior
Repair to the operation. In the operating room, it looks to be in good
Replacement uids should be given while monitoring position. However, postoperatively, when the patient is seated the
standard parameters of resuscitation. Serum electrolytes ileostomy is low, making care difcult.
should be checked and replaced as needed. Loperamide
has been shown to decrease ileostomy output by 22%.10
Bismuth subgallate, lomotil, tincture of opium, and
codeine sulfate have also been shown to reduce ileos-
tomy output.11
Stoma Retraction
Prevention
During surgery, every effort should be made to pre- Consequence
serve the distal small bowel and use the most distal Leakage around the stoma, leading to peristomal skin
portion of the small bowel for the ileostomy. Postop- irritation. Retraction of a loop ileostomy can result in
eratively, ileostomy output should be carefully mea- incomplete defunctionalization of the distal bowel.6,12
sured and recorded. On discharge, patients should be Stoma retraction occurs in up to 17% of ileostomy
instructed and taught to continue to track the stoma patients followed for 20 years.13
output. Grade 3 complication

Figure 223 To determine the depth of ischemia or necrosis of
a stoma, a test tube is gently inserted into the stoma opening. A
penlight is used to help visualize the mucosa. If the ischemia extends
below the fascial level, an urgent laparotomy is required.
Repair
Stoma revision may be accomplished by a local proce-
dure at the ileostomy site, but the majority of cases will
require a laparotomy.
Prevention
Stoma retraction is caused by tension on the bowel or
loss of the distal stoma from necrosis. Retraction often
is associated with a high body mass index.14 In obese
patients, an end-loop ileostomy should be considered.
Some data indicate a higher rate of retraction in con-
taminated stoma cases, although this is not specic for
ileostomies.15
Necrotic/Ischemic Stoma
Consequence
Supercial necrosis of the stoma, resulting in stenosis
or retraction of the stoma. If the ischemic segment
extends below the fascia, peritonitis can result. A simple
bedside test can be performed to assess the depth of
necrosis (Fig. 223).
Grade 2/3 complication
Repair
Supercial necrosis can be observed. If it results in
stenosis or difculty tting the appliance, the stoma will
need to be revised. If the ischemic segment extends
below the fascia, an emergent laparotomy is required.
Prevention
Mesenteric tension or excessive trimming of the mes-
entery may result in an ischemic stoma. The last vascu-
lar arcade of the small bowel mesentery should be
preserved. Again, consideration should be given to
constructing an end-loop ileostomy, especially in obese
patients.
22 ILEOSTOMY 249
Figure 224 Ischemia at the distal end of the ileostomy or
tension on the mesentery of the bowel can lead to stenosis. This
will make it difcult for the patient to properly t the appliance.
Stoma Stenosis
Consequence
Difculty tting the appliance, stoma leakage, and
noise while passing atus (Fig. 224).
Grade 2/3 complication
Repair
If the stenosis is at the skin level, local repair is possible.
In cases resulting from ischemia or Crohns disease, a
formal laparotomy is usually required.
Prevention
Stenosis is believed to be secondary to ischemia of the
distal bowel or to result from tension at the mesentery.
See comments for Prevention in the section on
Necrotic/Ischemic Stoma, earlier.
Skin and Subcutaneous Tissue Incision
Mucocutaneous Separation
Consequence
Difculty tting the appliance, leading to breakdown
of the skin around the stoma.
Grade 2/3 complication
Repair
Local revision is possible in simple cases. V-Y aps have
been used to decrease the size of the incision.16 In
extreme cases, laparotomy and resitting of the stoma
may be necessary.
Prevention
Proper assessment of the diameter of the bowel to be
used for the stoma. It is generally advisable to start
small and increase the size as needed.
 250 SECTION III: GASTROINTESTINAL SURGERY

Alignment of the Layers of the Abdominal Wall
and Incision of the Anterior Rectus Fascia
Peristomal Hernia
Consequence
Difculty tting the appliance, bowel obstruction, and Repair
strangulation leading to bowel ischemia. Loop ileosto-
mies are associated with a 1% to 3% incidence of peri-
stomal hernia. For end ileostomies, the rate is between
6% and 7%. The cumulative probability after 20 years
of developing a peristomal hernia is 16% (Figs. 225
and 226).
Grade 3 complication
Repair
Local tissue repairs overall have poor results, with
recurrence rates ranging from 40% to 100%. Stoma
relocation fares slightly better, with recurrence rates
ranging from 0% to 76%. Mesh repairs have the lowest
reported recurrence rate (0%33%), but carry the risk
of infection in a contaminated eld.17
Prevention
The fascial incision should be just large enough to
allow passage of the limb of bowel, generally 2.5 cm.
Whereas it is generally believed that placing the
stoma through the rectus muscle reduces the incidence
of a peristomal hernia, the data are mixed18,19 (Fig.
227).
Stoma Prolapse
Consequence
Difculty tting the appliance and irritation of the
bowel. In extreme cases, incarceration of the prolapsed
bowel may occur, leading to strangulation. The cumu-
lative risk of prolapse over a 20-year period is approxi-
mately 11%.13
Grade 2/3 complication
Local revision of the stoma with excision of the pro-
lapsed bowel is generally required. In cases of incar-
ceration, application of sugar on the edematous bowel
will act as an osmotic agent and may reduce the bowel.
Strangulated bowel requires an emergent laparotomy
and stoma revision.
Prevention
See comments for Prevention, in the section on
Parastomal Hernia, previously.
Separation of the Rectus Fibers
Injury to the Inferior Epigastric Vessels
Consequence
Excessive bleeding.
Grade 1 complication
Repair
Ligation of the vessel.
Prevention
Careful separation of the rectus bers by spreading in
a longitudinal direction may reduce the risk of injury
to this vessel (Figs. 228 and 229).
Incision of the Posterior Rectus Fascia
and Peritoneum
Parastomal Hernia and Prolapse
See the section on Alignment of the Layers of the
Abdominal Wall and Incision of the Anterior Rectus
Fascia, earlier.

Injury to the Underlying Bowel

Consequence
Enterotomy, possible peritonitis postoperatively if not
identied at the time of injury.
Grade 2/3 complication

Repair
Primary repair or resection as required.
Figure 225 Although there are no specic data regarding the
exact size of the stoma opening, either too large or too small an Prevention
opening can lead to complications. In general, the stoma incision The assistant should place a laparotomy pad under the
should be two ngerbreadths for a loop ileostomy and slightly peritoneum and lift up the undersurface of the abdom-
smaller for an end ileostomy. inal wall (Fig. 2210).
 22 ILEOSTOMY 251

Lateral edge of
rectus muscle Medial edge of
rectus muscle

Fascial edge

Skin

Stoma opening

Skin
Fat

Clamps

Ructus muscle

B Fascia
Figure 226 Hidden anatomy. A, In patients with thick abdominal walls, the fascia tends to retract laterally relative to the midline skin
incision. If proper alignment is not restored, the stoma opening will be made tangential to the muscular wall of the abdomen. The opening
in the fascia for the stoma will be too close to the midline incision. This can lead to difculty closing the midline incision and could result
in kinking of the bowel as it traverses the abdominal wall. B, By placing a clamp on the fascia and on the dermal layer of the midline
incision, proper alignment can be restored.

pressure should be exerted from the abdominal side to

Passing the Bowel through the Stoma Opening
deliver the bowel segment onto the skin surface.
Tearing the Bowel
Twisting of the Bowel
Consequence
Enterotomy, contamination of eld, and possibly peri- Consequence
tonitis if not identied at the time of injury. Bowel obstruction, ischemia, and maturing wrong end
Grade 2/3 complication of a loop ileostomy.
Grade 2/3 complication
Repair
Use the enterotomy site as the stoma opening if Repair
possible; otherwise, primary repair or resection is Rotate bowel for proper alignment if noted intraop-
required. eratively; otherwise reoperation is required.
Prevention Prevention
The bowel should be guided through the abdominal For an end ileostomy, following the divided mesentery
wall from the skin side, but not pulled. Rather, gentle of the right colon up to the underside of the
 252 SECTION III: GASTROINTESTINAL SURGERY
Figure 227 At the base of this stoma incision, the bers of the
external oblique muscles can be visualized. Most surgeons believe
that placing a stoma in this location increases the possibility of
hernia formation.
Figure 228 To reduce the chance of injury to the inferior
epigastric vessel, the rectus muscle should be separated in the
direction of its bers. (Adapted from Wu JS. Ileostomy. Oper Tech
Gen Surg 2003;5:257263.)
Figure 229 A clamp is passed through the stoma opening.
When the surgeon grasps the tip of the clamp, the abdominal wall
can be closely inspected for signs of bleeding. The inferior epigastric
artery lies just below the rectus muscle.
Figure 2210 Proper alignment of the skin and fascial layers is
crucial to ensure that the bowel passes perpendicular to the
abdominal wall. A Kocher clamp is placed on the rectus fascia and
a second on the dermal layer. A folded lap pad is placed under the
stoma site. The assistant holds the two clamps and presses up on
the underside of the abdominal wall.
 22 ILEOSTOMY 253

Figure 2211 Once the bowel has been passed through the
abdominal wall, it is essential to be certain that it is not rotated.
Placing a seromuscular suture through one side of a loop ileostomy Figure 2212 Skin implants at the mucocutaneous junction are
can help maintain proper orientation. the result of passing a suture through the epidermal skin layer.
Ideally, the suture should be placed at the dermal level. (Reprinted
abdominal wall will ensure proper alignment. For a with permission from Wu JS. Ileostomy. Oper Tech Gen Surg
loop ileostomy, marking one side with a seromuscular 2003;5:257263.)
suture is helpful, but careful attention to detail is essen-
tial (Fig. 2211).

Placing the Bridge and Maturing the Stoma

Enterocutaneous Fistula
Consequence
Poor-tting appliance and peristomal irritation. Fistulas
develop in 7% to 11% of ileostomy patients with Crohns
disease.20
Grade 2/3 complication
Repair
Simple stulas may be amenable to local revision of the
stoma. In patients with Crohns disease, laparotomy
with resection of the distal bowel and peristomal skin
and revision of the stoma are frequently required.21
Prevention
Fistulas arise either from a technical error maturing the
ileostomy, Crohns disease, or pressure necrosis from
the appliance on the side of the ileostomy (Fig. 2212).
When the end of the ileostomy is being everted, the
rst bite should be full thickness through the distal cut
edge of the bowel. The second should be a seromus-
cular bite approximately 5 cm proximal to the cut edge.
A full-thickness bite at this level has the potential to
develop into a stula. Finally, the last bite should be of
the dermis at the edge of the ileostomy incision. Placing
the suture full thickness through the skin can lead to
mucosal implants around the stoma (Fig. 2213). Care
should be taken to avoid pressure from the stoma wafer Figure 2213 The appliance has irritated the side of the ileos-
on the ileostomy. tomy. If this is not corrected, it can result in stula formation.
 254 SECTION III: GASTROINTESTINAL SURGERY
Other Complications
Diversion Colitis
Grade 1 complication
Segments of the colon excluded from the fecal stream can
develop inammatory changes. Up to 50% of patients
experience symptoms, commonly mucous discharge,
abdominal pain, or low-grade fevers. The endoscopic
appearance of the diverted segment can be normal or
inamed. Diversion colitis is believed to be caused by the
absence of luminal short chain fatty acids, which are used
as an energy source for colonic mucosal cells. Symptoms
generally resolve with closure of the ileostomy.22 In cases
in which this is not possible, short chain fatty acid enemas
may be useful.23,24
Pyoderma Gangrenosum
Grade 1 complication
Pyoderma gangrenosum is a chronic, painful ulceration of
the skin associated with inammatory bowel disease.
Although it usually affects the lower extremity, several
cases of peristomal pyoderma gangrenosum have been
described. The painful ulcerations around the stoma create
difculty tting the appliance. Meticulous care of the
stoma is essential. Injection of corticosteroids, iniximab,
antibiotics, and systemic steroids have all been tried with
limited success.25
Carcinoma
Grade 3/4/5 complication
Forty-four cases of primary adenocarcinoma of an ileos-
tomy have been reported in the literature. The average
time from creation of the ileostomy to appearance of the
adenocarcinoma is 24 years. The pathologic features
suggest a transition from ileal mucosa to colonic mucosa
to colonic dysplasia to adenocarcinoma. Chronic irritation
of the stoma may predispose the ileal mucosa to these
changes. Patients with ileostomies older than 15 years
should be followed closely for this complication.26 Stomal
excision is advised for any dysplastic changes, and segmen-
tal excision is recommended for adenocarcinoma.27
Stomal Varices
Grade 3/4/5 complication
Patients with portal hypertension may develop varices at
the mucocutaneous junction. Local control measures and
revision of the mucocutaneous junction may provide local
control. Portal decompression or liver transplantation
offers a more permanent solution.28
REFERENCES
1. Khoo RE, Montrey J, Cohen MM. Laparoscopic loop
ileostomy for temporary fecal diversion. Dis Colon
Rectum 1993;36:966968.
2. Den Dulk M, Smit M, Peeters KMJ, et al. A multivariate
analysis of limiting factors or stoma reversal in patients
with rectal cancer entered into the total mesorectal
excision (TME) trial: a retrospective study. Lancet Oncol
2007;8:278279.
3. Nugent KP, Daniels P, Stewart B, et al. Quality of life in
stoma patients. Dis Colon Rectum 1999;42:15691574.
4. Gooszen AW, Gelkerken RH, Hermans J, et al. Quality of
life with a temporary stoma: ileostomy vs. colostomy. Dis
Colon Rectum 2000;43:650655.
5. Robertson I, Leung E, Hughes D, et al. Prospective
analysis of stoma-related complications. Colorectal Dis
2005;7:279285.
6. Feinberg SM, McLeod RS, Cohen Z. Complications of
loop ileostomy. Am J Surg 1987;153:102107.
7. Bass EM, Del Pino A, Tan A, et al. Does preoperative
stoma marking and education by the enterostomal
therapist affect outcome? Dis Colon Rectum 1997;40:
440442.
8. Tang CL, Yunos A, Leong APK, et al. Ileostomy output
in the early postoperative period. Br J Surg 1995;82:607.
9. Wexner SD, Taranow DA, Johansen OB, et al. Loop
ileostomy is a safe option for fecal diversion. Dis Colon
Rectum 1993;36:349354.
10. Tytgat GN, Huibregtse K, Meuwissen SG. Loperamide in
chronic diarrhea and after ileostomy: a placebo-controlled
double-blind cross-over study. Arch Chir Neerl 1976;28:
1320.
11. Kramer P. Effect of antidiarrheal and antimotility drugs on
ileal excreta. Am J Dig Dis 1977;22:327332.
12. Winslet MC, Drolc Z, Allan A, Keighley MRB. Assess-
ment of the defunctioning efciency of the loop ileos-
tomy. Dis Colon Rectum 1991;34:699703.
13. Leong APK, Londono-Schimmer EE, Phillips RKS. Life-
table analysis of stomal complications following ileostomy.
Br J Surg 1994;81:727729.
14. Arumugam PJ, Bevan L, Macdonald L, et al. A prospec-
tive audit of stomasanalysis of risk factors and complica-
tions and their management. Colorectal Dis 2003;5:49
52.
15. Leenen LPH, Kuypers JHC. Some factors inuencing the
outcome of stoma surgery. Dis Colon Rectum 1989;32:
500504.
16. Edington HD, Lorze MT. V-Y closure for abdominal wall
stomal reduction. Surg Gynecol Obstet 1987;164:381
382.
17. Carne PWG, Robertson GM, Frizelle FA. Parastomal
hernia. Br J Surg 2003;90:784793.
18. Sjodahl R, Anderberg B, Bolin T. Parastomal hernia in
relation to site of the abdominal stoma. Br J Surg 1988;
75:339340.
19. Williams JG, Etherington R, Hayward MWJ, Hughes LE.
Paraileostomy hernia: a clinical and radiological study. Br J
Surg 1990;77:135137.
20. Shellito PC. Complications of abdominal stoma surgery.
Dis Colon Rectum 1998;41:15621572.
21. Greenstein AJ, Dicker A, Meyers S, Aufses AH. Periileos-
tomy stulae in Crohns disease. Ann Surg 1983;197:179
182.
22. Giardiello FM, Lazenby AJ. The atypical colitides.
Gastroenterol Clin North Am 1999;28:479490.
23. Harig JM, Soergel KH, Komorowski RA, et al. Treatment
of diversion colitis with short chain fatty acids irrigation.
N Engl J Med 1989;320:2328.

24. Kiely EM, Ajayi NA, Wheeler RA, Malone M. Diversion
procto-colitis: response to treatment with short-chain fatty
acids. J Pediatr Surg 2001;36:15141517.
25. Kiran RP, OBrien-Ermlich B, Achkar JP, et al. Manage-
ment of peristomal pyoderma gangrenosum. Dis Colon
Rectum 2005;48:13971403.
26. Quah HM, Samad A, Maw A. Ileostoma carcinomas a
review: the latent risk after colectomy for ulcerative colitis
and familial adenomatous polyposis. Colorectal Dis 2005;
7:538544.
22 ILEOSTOMY 255
27. Gadacz TR, McFadden DW, Gabrielson EW, et al.
Adenocarcinoma of the ileostomy: the latent risk of cancer
after colectomy for ulcerative colitis and familial polyposis.
Surgery 1990;107:698703.
28. Roberts PL, Martin FM, Schoetz DJ, et al. Bleeding
stomal varices: the role of local treatment. Dis Colon
Rectum 1990;33:547549.
COLON, RECTUM AND ANUS
Eugene F. Foley, MD
23
Right Colectomy: Open and
Laparoscopic
David W. Larson, MD
INTRODUCTION
The operative choices available for right colectomy
expanded in May of 2004. With the publication of Clini-
cal Outcomes Surgical Therapy (COST),1 laparoscopic or
minimally invasive surgery (MIS) for the treatment of
malignant disease had the evidence needed to ethically
offer it to patients with cancer. Since the early 1990s,
laparoscopic colectomy for benign and, more importantly,
malignant disease suffered from poor adoption. The
reasons for this are many, including technical difculty,
poor instrumentation, and concerns over the oncologic
impact of laparoscopic surgery. These important factors
and concerns crystallized the importance of open right
colectomy as the standard by which MIS is judged. Despite
the slow growth of MIS, the evidence supplied by
trials like COST, Conventional vs. Laparoscopic Assisted
Surgery in Colorectal Cancer (CLASICC), and Colon
Cancer Laparoscopic or Open Resection (COLOR)13
have allowed for the dramatic increase in the use of this
technique.
Right colectomy remains a classic and standard opera-
tion that results in outstanding outcomes with relatively
few lasting complications. However, even well-known and
successful operations have pitfalls. These potential prob-
lems can be avoided by careful planning and meticulous
technique. The best data to date would suggest that mor-
bidity associated with this procedure is around 20% with
2% to 4% of these occurring intraoperatively.1,3 Most com-
plications from this operation involve two areas: those
common to all operations of the right colon and those
important to cancer specically. The complications
common to all operations of the right colon include trocar
complications (<1%), bleeding (1%4%), bowel injury
(1%2%), ureteral injury (1%), wound infection and dehis-
cence (2%5%), anastomotic failure (2%3%), deep vein
thrombosis (DVT; 1%2%), and death (0.5%5%).13
Complications related to oncologic concern arise mainly
from the risk of trocar site implants and the inability to
adequately assess the abdomen for metastatic disease.
Trocar site recurrences have been reported as high as 24%,4
although with the publication of recent randomized
trials, the percentage, in the setting of well-trained sur-
geons, should approach only 1%.1 This rate of recurrence
is similar to that seen in open surgery. Although failure
to detect metastatic disease is a risk, with proper pre-
operative work-up, this risk remains small and can be
attested to by the results of the COST, CLASICC, and
COLOR trials.13
INDICATIONS
Pathology of the right colon includes a number of benign
and malignant conditions.
Endoscopically unresectable polyps
Malignancy (adenocarcinoma, carcinoid)
Inammatory bowel disease (IBD)Crohns disease
OPERATIVE STEPS
Step 1 Positioning and/or trocar placement
Step 2 Thorough exploration of the abdomen with
both malignant disease and IBD
Step 3 Mobilization of the distal small bowel and
cecum
 258 SECTION III: GASTROINTESTINAL SURGERY
Figure 231 Trocar site placement. (By permission of Mayo
Foundation for Medical Education and Research. All rights
reserved.)
Step 4 Mobilization of the hepatic exure
Step 5 Vascular control
Step 6 Anastomotic techniques
Step 7 Closure
OPERATIVE PROCEDURE
Positioning and Trocar Placement
All operations begin with positioning. It is our practice to
position patients on the table in a supine position. Ankle
straps are utilized in both open and laparoscopic tech-
niques to allow for Trendelenburg position. The surgeon
stands on the patients left and across from the rst assis-
tant. Trocar placement can be seen in Figure 231.
Trocar Injuries and Future Wound
Site Recurrence
Consequence
Injuries associated with trocar placement can be life-
threatening. Although relatively uncommon, bowel
injury and intra-abdominal or abdominal wall bleeding
can occur. Likewise, the association of port site recur-
rence with malignancy secondary to poor technique
remains an important aspect of trocar use. The conse-
quences and repair of such injury are self-evident.
Grade 25/5 complication
Prevention
We suggest that the placement of the rst trocar be
performed in either an open or a modied open tech-
nique. The modied open technique of placing the
camera through a transparent trocar and passing it
under direct vision through the abdominal wall pro-
vides a signicant advantage in many obese patients or
those with a hostile abdomen. Once the rst trocar
is placed and secured, all other trocars are placed under
direct vision after appropriate insufations. Care must
be taken when placing any lateral port to avoid the
inferior epigastric vessel. If bleeding from the abdomi-
nal wall occurs, cautery, suture ligation, or tamponade
can be used. Specically, the use of a small Foley cath-
eter placed through the trocar with subsequent ina-
tion of the balloon and back-pressure on the abdominal
wall will stop most bleeding.
Prevention of port site recurrence includes making sure
all trocars are securely in place and allowing gas to escape
only through the trocars. By preventing gas or irrigation
from exiting the abdomen around or through an unpro-
tected trocar site, you will prevent the so-called chimney
effect, which has been theorized as the cause for the high
rates of recurrence.
Exploration
Exploration is a critical step in the surgical management
of both benign and malignant disease. It remains most
critical for malignant disease because rates of unsuspected
M1 disease range from 1% to 4%.1 Once the abdomen is
entered, a thorough exploration of the abdomen is the
rst order of business. The liver must be palpated or visu-
alized in the case of laparoscopic surgery, the gallbladder
must be assessed for stones, and the surrounding organs
of the upper and midabdomen must be examined. The
small bowel is run from the ligament of Treitz to the
ileocecal valve. In women, the uterus and ovaries must
be inspected for any pathology because metastatic disease
may occur in up to 3% of patients. One must remember
that intraoperative ultrasound can also be used to enhance
the hepatic evaluation for metastasis. During exploration,
we determine whether adhesions, altered anatomy, or
tumor characteristics will require conversion to open
surgery. If so, conversion is performed promptly.
Consequence
Improper exploration will lead to incomplete operation
in both malignancy and IBD.
Grade 25/5 complication
 23 RIGHT COLECTOMY: OPEN AND LAPAROSCOPIC 259

Repair
If metastatic disease is identied, surgical resection of
isolated metastatic disease or biopsy of unresectable
metastatic disease may take place. In the setting of
multisite IBD, further surgical intervention such as
strictureoplasty, resection, or bypass may be used.

Prevention
In the setting of malignant disease, preoperative staging
with computed tomography (CT), laboratory evalua-
tion, and physical examination will have lower than 1%
risk of identifying unsuspected M1 disease, as attested
to by COST.1 Special consideration should be given to
locally aggressive tumors. If adjacent organs are involved
such as duodenum, small bowel, omentum, or retro-
peritoneal structures such as the ureter or gonadal
vessels, every attempt must be made to complete an
en-bloc resection. The surgeon must not violate
oncologic principles by attempting to separate
intra-abdominal structures from the tumor because this
would adversely affect patient outcome. A R0 resection
must be the goal of every operation regardless of
technique.

Mobilization of the Cecum and Small Bowel

Although technical details differ between open and lapa-
roscopic surgery, the actual dissection remains exactly the
same. For a right colon cancer, the line of dissection
depends on the location of the tumor. For tumors located
in the cecum, a 10-cm margin of terminal ileum is gener-
ally taken. If the tumor is located in the ascending colon,
only a few centimeters of ileum is required as a margin.
This line of resection should extend to the transverse
colon at the level of the right branch of the middle
colic vessels (Fig. 232). Ureteral injury and adjacent
bowel injury are most likely during this portion of the
dissection.
Injury to the Ureter (1%) or the Surrounding
Small Bowel (1%3%) (Thermal Injury)
Consequence
The degree of complication depends on the extent of
the injury and the timing of the repair.
Grade 24/5 complication (ureteral injury); grade
25/5 complication (small bowel injury)
Repair
Primary repair of the ureter over a stent or repair of the
small bowel injury can be performed either laparo-
scopically or in an open fashion depending on the
surgeons comfort level. In the setting of thermal injury
that is not full thickness, the use of an oversew stitch
or buttressing the area with an omental patch may
prove useful.
Figure 232 Line of resection for a right hemicolectomy
done for cancer. (By permission of Mayo Foundation for Medical
Education and Research. All rights reserved.)
Prevention
Prevention starts with meticulous technique and proper
equipment and retraction. The patient is placed in the
Trendelenburg position with the right side tilted up.
The rst step of dissection is ureter identication, which
can usually be done at the level of the pelvic brim. In
obese patients, one must rst score the peritoneum to
identify the ureter. With appropriate retraction and
positioning, one can separate the bowel of interest from
loops of adjacent bowel. It is important to understand
the intrinsic limitations of the different dissection tools
we have at our disposal from sharp dissection to elec-
trocautery to ultrasonic dissectors to various radiofre-
quency devices. Each has its own intrinsic risk of
injuring adjacent structures, and one must be con-
stantly aware of ones surrounding, especially with a
laparoscopic approach.
Mobilization of the right colon begins by separating
the retroperitoneal structures (gonadal vessels and ureter)
from the terminal ileum and cecum. This is performed by
incising the virtually transparent peritoneal attachments to
these structures laterally and rotating the cecum anteriorly
and medially (Fig. 233). Once this mobilization is com-
pleted, the medial and posterior attachments to the right
 260 SECTION III: GASTROINTESTINAL SURGERY
Figure 233 A, Lateral line of dissection for open right colec-
tomy. B, Lateral to medial dissection of the cecum and ascending
colon. (A and B, By permission of Mayo Foundation for Medical
Education and Research. All rights reserved.)
Figure 234 Inferior and medial dissection of the cecum and
ascending colon. (By permission of Mayo Foundation for Medical
Education and Research. All rights reserved.)
colon and terminal small bowel are incised up toward the
junction of the third and fourth portions of the duode-
num (Fig. 234). Mobilization of the colon and the ileo-
colic vessel is complete once the surgeon has identied
the middle colic vessel as it crosses the inferior border of
the duodenum.
Hepatic Flexure Mobilization
Continuing the lateral dissection up and around the
hepatic exure during open resection, the surgeons
index nger provides the plane of dissection for the rst
assistant to cauterize upon (Fig. 235). Retracting the
midtransverse colon inferiorly, one can complete the
exposure of the hepatic exure. The thin plane between
the mesocolon and the gastrocolic ligament can be
developed bluntly and dissected to complete the exure
mobilization. Once this has been completed, the right
colon is retracted superiorly and medially, exposing the
anterior edge of the duodenum and head of the pancreas.
Release of these lmy attachments is the last step in the
dissection.
Similarly, the laparoscopic approach begins medially at
the transverse colon and proceeds toward the previous
 23 RIGHT COLECTOMY: OPEN AND LAPAROSCOPIC
Figure 235 Line of resection for the lateral peritoneal attach-
ments of the right colon and hepatic exure. (By permission of
Mayo Foundation for Medical Education and Research. All rights
reserved.)
lateral dissection of the cecum and ascending colon. The
patient is placed in reverse Trendelenburg with the right
side up. Mobilization of the colon at the hepatic exure
begins with the gastrocolic ligament, which is grasped
near but not on the bowel and elevated toward the ante-
rior abdominal wall and the feet. This thin ligament can
often be separated from the deeper tissues of the colonic
mesentery. By identifying and then entering the correct
plane between the gastrocolic ligament and the transverse
colon mesentery, one can easily mobilize the hepatic
exure. Proper mobilization allows for visualization of the
duodenum, which is protected (Fig. 236). Once these
planes of dissection are connected, the remaining lmy
attachments anterior to the duodenum are divided, in a
manner similar to that performed in the open approach.
Duodenal Injury
Consequence
Perforation or delayed perforation with peritonitis.
Grade 25/5 complication
Repair
As stated in the previous section, if injury is noted, one
must repair the defect. If noted during a laparoscopic
resection, one can either convert and repair or repair
with laparoscopic techniques.
261
Figure 236 Hepatic exure mobilization, laparoscopic tech-
nique. (By permission of Mayo Foundation for Medical Education
and Research. All rights reserved.)
Prevention
Meticulous dissection at the level of the duodenum and
around the head of the pancreas is the standard that
must be upheld. During laparoscopic dissection, this
area is at particular risk, given the more limited nature
of retraction. It is, therefore, crucial to elevate the
gastrohepatic ligament off the retroperitoneal structure
prior to dissecting them (see Fig. 236). Without this
critical step, one is apt to place the duodenum at risk
for thermal or ultrasonic injury. It is important that the
dissection of the cecum and the posterior and medial
attachments up to the duodenum be completely freed
(see Fig. 234). This mobilization will allow for greater
separation of tissues that now hold the hepatic exure
close to the duodenal edge.
Vascular Control
The avascular window between the right branch of the
middle colic artery and the right or ileocolic artery is an
important anatomic landmark. The right colic artery rarely
branches directly off the superior mesenteric artery (SMA).
The right colic most often (90% of the time) is a branch
of the ileocolic artery and rarely requires separate ligation.
The vessels of interest in an operation for cancer are, of
course, the ileocolic, the right colic, and the right branch
of the middle colic.
 262 SECTION III: GASTROINTESTINAL SURGERY
Figure 237 Intracorporeal vascular ligation. Pedicle ligation of
the ileocolic and right colic artery is accomplished with the use of
a laparoscopic device. (By permission of Mayo Foundation for
Medical Education and Research. All rights reserved.)
Consequence
Bleeding (1%2%).
Grade 12/5 complication (if at the time of opera-
tion); grade 35/5 complication (if delayed)
Repair and Prevention
Again, one must know the limitations of each particu-
lar method of ligation. The rst step in proper ligation
either laparoscopically or in the open approach begins
with the avascular area between the ileocolic and the
right branch of the middle colic vessel. This space is
incised down to the base of the ileocolic vessels at the
level where it crosses the lateral or inferior edge of
the duodenum (Fig. 237). The peritoneum overlying
the ileocolic and right colic vessels is incised, and the
vessels are doubly ligated and/or divided with a lapa-
roscopic device. Next, the marginal branches to the
ileum are divided, thus preparing the proximal line of
resection. The nal step divides the marginal and the
right branch of the middle colic artery.
Anastomosis
For the purpose of this chapter, the techniques of anasto-
mosis are the same for both the laparoscopy-assisted and
the open approach. Although exposure is certainly differ-
ent between the two approaches, both are performed
extracorporeally.
Consequences
Anastomotic leak occurs in 2% to 3% of patients.
Grade 35/5 complication
Repair and Prevention
Standard surgical dictum of proper blood supply,
limited tension, and meticulous technique is the hall-
mark of every successful anastomosis. Our techniques
include two broad categories of anastomosis: hand-
sewn and stapled anastomoses. Three standard anasto-
motic techniques can be performed: end-to-end,
side-to-side, or end-to-side.5
Hand-Sewn Anastomosis (Fig. 238)
With this anastomosis, our preference is to rst make
certain that the two ends of bowel are approximated. We
use 3-0 stay sutures in the corners of the bowel to aid with
approximation. A posterior row of Lembert sutures is
placed rst. These sutures should be placed deep enough
to incorporate most of the muscle layer. Next, an inner
layer of running 3-0 suture is used to approximate the
mucosal and submucosal layers. The corner of the bowel
is secured rst, and the running suture is then advanced
along the posterior aspect of the anastomosis. This suture
is continued around the opposite corner to complete the
anterior mucosal approximation. The suture is then tied
to itself at the corner. The occluding bowel clamps are
removed from the bowel to allow blood ow to return to
the ends of the bowel. The nal step includes the anterior
second layer of 3-0 Lembert sutures approximating the
serosal layer, thus, bolstering the anastomotic line.
Stapled Anastomosis (Fig. 239)
Our standard stapled functional end-to-end anastomosis6
employs two rings of a disposable linear cutting stapler.
On the specimen side of the resection line, a 1-cm trans-
verse incision is made on the antimesenteric borders of
the ileum and colon. Placing one of the two sides of the
linear cutting stapler into each of the holes in the small
bowel rst and then the colon, the stapler is gently closed,
approximating the small bowel and the colon along the
antimesenteric border. Ensuring that the mesentery is
clear and the stapler is in good position, it is red and
then removed. Upon doing this, the previously separate
ileal and colonic enterotomies become joined into a single
enterotomy, and a pair of Babcock clamps are used to
grasp opposite borders of this enterotomy at the anterior
and posterior staple lines. A reloaded, long (75100-mm)
linear cutting stapler is then placed across the ileum and
transverse colon, at a right angle to the previous staple
line. By retracting the previous enterotomy, the stapler is
red, completing the surgical resection and anastomosis.
 23 RIGHT COLECTOMY: OPEN AND LAPAROSCOPIC 263

Figure 238 A, Hand-sewn anastomosis. Posterior row of interrupted suture. B, Posterior running layer of suture. C, Anterior running
layer of suture. D, Anterior row of interrupted suture. (AD, By permission of Mayo Foundation for Medical Education and Research. All
rights reserved.)

Other Complications
Wound Infection or Dehiscence
Grade 12/5 complication
Postoperative wound infections have been a chronic
problem for all bowel surgery, affecting 2% to 5% of
patients undergoing this operation.13 The data from the
three randomized trials have not found any improvement
for those patients who undergo a laparoscopic approach.13
Recently, new wound-protecting devices along with con-
tinued proper tissue handling and perioperative antibiotic
may reduce this risk, but the data on this subject are
limited. It is our standard practice to utilize a wound-
protecting device on all our laparoscopic cases.
Deep Vein Thrombosis
Grade 12/5 complication
Standard treatment with subcutaneous heparin or
low-molecular-weight heparin 1 to 2 hours prior to oper-
ation and postoperatively as well as concomitant use of
pneumatic compression and compression stockings have
proved efcacy in abdominal operations. These treatments
are most important for those patients with increased risk
factors for venous thrombotic events such as cancer and
IBD. Early ambulation will also decrease the risk of this
particular morbidity.
CONCLUSION
Surgical resection of the right colon is a classic standard
operation in the training of all surgeons. Surgical tech-
nique and anatomic dissection are the keys to oncologic
outcome and postoperative success, regardless of the tech-
nique employed. Following these principles will allow
continued excellent outcomes.
 264 SECTION III: GASTROINTESTINAL SURGERY

Figure 239 A, Stapled anastomosis. One-centimeter transverse incisions are made on the antimesenteric borders of the ileum and
colon to begin a stapled anastomosis. B, First staple line in the stapled anastomosis. C, Second staple line, which completes the stapled
anastomosis. D, Oversewing the staple line with interrupted suture. (AD, By permission of Mayo Foundation for Medical Education and
Research. All rights reserved.)

REFERENCES outcomes of a randomised trial. Lancet Oncol 2005;6:477

1. A comparison of laparoscopically assisted and open
colectomy for colon cancer. N Engl J Med 2004;350:
20502059.
2. Guillou PJ, Quirke P, Thorpe H, et al. Short-term end-
points of conventional versus laparoscopic-assisted surgery
in patients with colorectal cancer (MRC CLASICC trial):
multicentre, randomised controlled trial. Lancet
2005;365:17181726.
3. Veldkamp R, Kuhry E, Hop WCJ, et al. Laparoscopic
surgery versus open surgery for colon cancer: short-term
484.
4. Berends FJ, Kazemier G, Bonjer HJ, Lange JF. Subcutane-
ous metastases after laparoscopic colectomy. Lancet 1994;
344:58.
5. Devine R, Pemberton JH. Right and left hemicolectomy.
In Donohue J, Van Heerden J, Monson J (eds): Atlas of
Surgical Oncology. Cambridge, MA: Blackwell Science,
1995; pp 215221.
6. Meagher AP, Wolff BG. Right hemicolectomy with a
linear cutting stapler. Dis Colon Rectum 1994;37:1043
1045.
24
Left Colectomy: Open and
Laparoscopic
Edward C. Lee, MD and Kelly Garrett, MD
INTRODUCTION
A left colectomy is indicated for pathologic processes
involving the distal third of the transverse colon, the
descending colon, and the sigmoid colon. In general,
this encompasses diseases such as diverticulitis, ischemic
colitis, segmental Crohns colitis, and neoplasms, both
benign and malignant. In resection of malignant diseases,
lymphatic drainage and blood supply generally control
the extent of dissection. A minimum of 5 cm on either
side of the lesion is considered an adequate margin. Bowel
margins are also important when resection is undertaken
for benign diseases.1 For instance, in the treatment of
diverticular disease, the entire distal sigmoid colon should
be removed and anastomosed to the rectum. It has been
shown that retaining a distal sigmoid cuff may contribute
to recurrent diverticulitis.2,3 In comparison, conservative
resection margins are recommended in the treatment of
inammatory bowel disease. The presence of residual
microscopic disease at resection margins has not been
shown to reduce recurrence rates. Therefore, resection
margins should be determined by gross inspection only.4
As a nal point, in benign diseases, dissection of the mes-
entery can be carried out at any level; however, it is most
often carried out at the same level as it is for malignant
disease for the sake of convenience in ligation of vessels
and lymphatics.1
Open left colectomy has traditionally been the opera-
tion of choice. Some literature has demonstrated laparo-
scopic colon resection to be a safe and practical approach
for resecting both benign and malignant diseases.58 Both
surgical procedures generally involve the same concept. In
the open procedure, however, dissection starts at the
white line of Toldt, whereas laparoscopically, it is often
done using a medial to lateral approach. Overall, a steep
learning curve, approaching between 30 to 70 cases, is
associated with the laparoscopic technique.9 However,
laparoscopic colectomies are gradually becoming the stan-
dard of care at major institutions. Patients undergoing
laparoscopic colectomy have been shown to resume a diet
quicker, to need less narcotic analgesia, to have a quicker
return of bowel function and a shorter hospital stay.6
This chapter reviews both the open and the laparosco-
pic procedures, along with their respective complications
and outcomes. Although each technique may differ with
regard to operative steps, the risks and pitfalls are similar.
INDICATIONS
Neoplasms involving the distal transverse colon, splenic
exure, descending colon, and sigmoid colon
Segmental Crohns colitis
Diverticulitis
Ischemic colitis
OPERATIVE STEPS
Open Procedure
Step 1 Incision of lateral peritoneal reection and mobi-
lization of sigmoid colon
Step 2 Identication of left iliac artery and ureter
Step 3 Mobilization along left pericolic gutter
Step 4 Takedown of gastrocolic ligament and enter
lesser sac
Step 5 Mobilization of splenic exure
Step 6 Division of proximal colon with gastrointestinal
anastomosis (GIA) stapler
Step 7 Ligation of mesenteric vessels
Step 8 Ligation of superior rectal artery
Step 9 Division of mesorectum
Step 10 Division of rectosigmoid colon with TA stapler
Step 11 Anastomosis with end-to-end anastomosis
(EEA) stapler or hand-sewing
Step 12 Test anastomosis with rigid sigmoidoscope
by lling with air while occluding lumen
proximally
Laparoscopic Procedure
Step 1 Trocar placement
Step 2 Retract sigmoid colon laterally and score medial
peritoneal attachment
 266 SECTION III: GASTROINTESTINAL SURGERY
Step 3 Identify superior rectal artery and left ureter
from medial to lateral
Step 4 Ligate superior rectal artery with GIA stapler
(vascular load)
Step 5 Develop plane between rectosigmoid and
mesorectum
Step 6 Division of rectosigmoid colon with GIA
stapler
Step 7 Division of mesorectum with harmonic scalpel
or GIA stapler (vascular load)
Step 8 Takedown of lateral peritoneal attachment
proceeding cephalad toward splenic exure with
harmonic scalpel
Step 9 Takedown gastrocolic ligament and enter lesser
sac
Step 10 Mobilization of splenic exure
Step 11 Extraction of left colon through umbilical port
after extension of port site incision
Step 12 Division of mesocolon
Step 13 Division of proximal colon extracorporally
Step 14 Pursestring suture and insertion of EEA anvil
into proximal colon
Step 15 Partial closure of umbilical incision, rein-
sertion of trocar, and reestablishment of
pneumoperitoneum
Step 16 Insertion of EEA through anus and intracorpo-
real anastomosis
Step 17 Test anastomosis with rigid sigmoidoscope
Step 18 Removal of trocars
OPERATIVE PROCEDURE
Incision of the Lateral Peritoneal Reection
and Mobilization of the Sigmoid Colon with
Ligation of the Superior Rectal Artery
Ureter Injury
The left ureter is in close proximity to the rectosigmoid
colon in the region where it crosses over the left common
iliac artery. Injuries to the ureter most commonly occur
while taking down the lateral peritoneal reection at the
white line of Toldt and during identication and ligation
of the superior rectal artery. When the colon is retracted
medially, the left ureter may be elevated with the sigmoid
mesocolon and mistaken for the superior rectal artery or
another mesenteric vessel10 (Fig. 241).
Consequence
Iatrogenic injury is most often to the left ureter. Injury
can occur in several ways during this step of the pro-
cedure. Most common injuries consist of complete
transection, excision of an entire segment or portion of
the ureteral wall, suture ligation, heat damage from
electrocautery, devascularization, or accidental crush
with a surgical clamp.10,11 Awareness of these injuries
allows for immediate repair. However, 50% to 70% of
Figure 241 In medial to lateral dissection, the left ureter is
swept lateral to medial to expose the superior rectal artery, as seen
here.
the time iatrogenic ureteral injuries go unnoticed until
symptoms become apparent postoperatively.10
Grade 2/3 complication
Repair
When injury to the ureter is recognized intraopera-
tively, urologic consultation should be obtained. The
plan for repair is based on the length and location of
the injury as well as the patients overall condition. One
third of iatrogenic injuries will involve the distal ureter.
These are primarily repaired with ureteroneocystos-
tomy and stent placement. Vesicopsoas hitch can be
done with greater loss of distal ureter length. Although
rare during left colectomy, upper and midureteral inju-
ries are generally repaired by ureteroureterostomy over
an internal stent. Transureteroureterostomy or a Boari
tabularized bladder ap is indicated with more signi-
cant loss of length. Other options include autotrans-
plantation and ileal transposition; however, these are
rarely indicated.10
Injuries identied during the postoperative course pre-
sent more of a challenge. Flank pain and fevers are the
most common presenting signs and symptoms. Other man-
ifestations include ureterovaginal and ureterocutaneous
stulas. Diagnosis is generally made by cystoscopy, and the
level of injury can be conrmed by retrograde pyelogram.12,13
If these injuries present within the immediate postopera-
tive period, operative intervention and repair are warranted.
When injury recognition is delayed further, endourologic
management with percutaneous nephro-stomy can be
carried out prior to denitive surgical repair.
Prevention
When the sigmoid colon is mobilized, the left ureter
should be identied as it crosses anterior to the common
iliac artery (Fig. 242). Before ligation of the superior
rectal artery and stapling through the rectosigmoid
junction, care should be taken to keep the location of
 24 LEFT COLECTOMY: OPEN AND LAPAROSCOPIC 267

Figure 242 In lateral to medial dissection, the left ureter is

swept medial to lateral to make the sigmoid colon into a midline
structure. In this dissection, stay as close to the sigmoid colon as
possible because all the critical structuresleft ureter, left iliac
vessels, and left gonadal vesselsneed to be exposed laterally.

the ureter in mind (Fig. 243A). Sometimes, it is useful

to identify the pulsation of the iliac artery and then look
for the ureter crossing over5 (see Fig. 243B). In the
open procedure, the ureter is generally mobilized later-
ally, whereas it is mobilized medially in the laparoscopic
procedure away from the superior rectal artery. Gentle
palpation is useful for identication; however, the
ureter should not be snapped or pulled. More so,
extensive skeletonization should not be performed
because of the risk of compromising the local blood
supply. This can result in ischemic necrosis.11 If there
is suspicion of a ureteral injury intraoperatively, 12.5 g
of mannitol can be injected intravenously followed by
5 ml of indigo carmine dye or methylene blue. The
diagnosis is made if blue dye inltrates the operative
eld.14 Some patients are considered at risk preopera-
tively secondary to a history of previous pelvic surgery,
radiation therapy, or large pelvic masses. In these cases,
the anatomy can be dened with a preoperative excre-
tory urogram and placement of ureteral stents prior to
incision.11 Stents do not absolutely protect against
injury but may help to clearly identify damage if and
when it occurs.
Vascular Injury
Consequence
During mobilization of the rectum and sigmoid, injury
to the gonadal and iliac vessels can occur. This results
in active hemorrhage with or without hypotension.
Early recognition of these injuries is important to avoid
subsequent morbidity.
Grade 1/2 complication
Repair
Ligation of the gonadal vessels in either sex does not
usually produce any harmful effects. This is due to the
ample collateral circulation to the gonads provided by
Figure 243 A, Prior to ligating or stapling the superior rectal
artery, once again the left ureter needs to be visualized crossing
under the artery and the stapler. B, Another situation in which the
left ureter may be injured is when ligating or stapling the mesorec-
tum. The left ureter needs to be identied coursing laterally medial
to the iliac vessels.
the artery to the vas deferens and external spermatic
artery in the male and the uterine artery in the
female.15
Injuries involving the iliac artery require repair. First
and foremost, it is important to gain proximal and distal
control. Placing sponge sticks on either side of the lesion
can provide hemostasis quickly. Repair of the artery can
be done by means of a lateral arteriorrhaphy with 4-0 or
5-0 polypropylene sutures. Injury to the iliac veins should
be exposed and controlled in a similar fashion. Repair can
be performed by a lateral venorrhaphy, being careful not
to cause narrowing of the vein, which can lead to subse-
quent thrombosis.16 In cases involving injuries to major
arteries and veins, consultation with a vascular surgeon is
benecial.17
Comparable injuries sustained during the laparoscopic
approach should initiate conversion to a laparotomy.18
Indications for conversion should include blood via
Veres needle aspiration, hemodynamic instability, active
 268 SECTION III: GASTROINTESTINAL SURGERY
Figure 244 Laparoscopically, the right ureter and the right iliac
vessels may be at risk because the dissection of the superior rectal
artery start from right to left or medial to lateral under the artery.
Care needs to be taken to stay close to the superior rectal artery
when making the peritoneal incision by the sacral promontory.
intra-abdominal hemorrhage, or an expanding retroperi-
toneal hematoma.19
Prevention
Similar to prevention of ureteral injuries, adequate visu-
alization and identication of anatomic structures and
their relationships can preclude vascular injury. This is
true for both the open and the laparoscopic approach.
In addition, laparoscopic injuries can also be avoided
by obtaining pneumoperitoneum using the open
(Hasson) technique as opposed to the percutaneous
insufation needle (Veres), inserting other trocars
under direct vision, elevating the abdominal wall prior
to trocar insertion, and training surgeons in laparo-
scopic techniques adequately.1820
Moreover, in the medial to lateral approach, the right
iliac vessels may be at risk. These injuries can be avoided
by dissecting close to the superior rectal vessels while
incising the peritoneum along the right sacral promontory
(Fig. 244).
Mobilization along the Left Pericolic Gutter,
Takedown of the Gastrocolic Ligament, and
Division of the Proximal Colon
Splenic Injury
Consequence
Iatrogenic splenic injury is uncommon, with percent-
ages ranging between 0.8% to 2.4%.21,22 This most
commonly occurs owing to inadequate exposure and
forceful traction on the colon during mobilization of
the splenic exure. Most injuries result from a capsular
tear with avulsion of a small segment of the splenic
pulp.14 Splenic salvage is preferred, however; occasion-
ally, splenectomy will need to be performed secondary
to uncontrollable bleeding.
Figure 245 When mobilizing the splenic exure, stay close to
the colon and away from the spleen. With a gentle downward
retraction, the splenocolic ligament, which is relatively avascular,
can be released.
Colon resection with concurrent splenectomy is associ-
ated with a vefold increased morbidity rate. The risk of
postoperative infectious complications in patients under-
going colorectal cancer surgery is approximately 50%
when splenectomy is also performed.23 Therefore, every
effort should be made to preserve the spleen.
Grade 3/4 complication
Repair
Attempt to control bleeding should begin with packing.
Efforts can be made to stop bleeding with several
maneuvers, including topical hemostatic agents such as
Gelfoam, thrombin, Fibrillar, or Surgicel. Use of an
argon beam coagulator has also been employed. If
blood loss continues, splenorrhaphy can be performed.
This can be accomplished by suture repair with Teon
pledgets and buttressing the repair with omentum if
necessary. More recently, a technique has been described
using topical hemostatic agents combined with a Vicryl
mesh wrap.24
Prevention
Splenic injury is best prevented by avoiding excess trac-
tion on the spleen, creating adequate visualization
during mobilization, and dissecting close to the colon
(Fig. 245). In the open technique, pushing in an
upward direction with the ngertips instead of pulling
caudad can avoid unnecessary pulling on the splenic
attachments.22 Another technique that has been sug-
gested entails early release of the spleen. This involves
mobilizing the spleen in the beginning of the operation
and has been shown to reduce the incidence of sple-
nectomy.25
In the laparoscopic approach, the patient is generally in
a reverse Trendelenburg position. Rotation of the patient
to the right side can help better visualize the splenic
 24 LEFT COLECTOMY: OPEN AND LAPAROSCOPIC 269

exure. Splenic injury seems to be less common in lapa-

roscopic surgery because the visualization is better and
forceful retraction is less.

Anastomosis
Anastomotic Leak
Consequence
Published leakage rates have been anywhere from 1.7%
to 5.1% in some studies.26,27 Anastomotic leaks generally
become apparent between postoperative days 4 and
12.28 Leaks may manifest with symptoms of generalized
peritonitis, as a localized collection found on fever work-
up, or as a subclinical leak detected on a contrast study.27
Predictive signs and symptoms include fevers and
leukocytosis, slow return of bowel function, diarrhea,
Figure 246 Hidden anatomy. When the proximal colon needs
increasing drain output, oliguria, and renal failure.28 more mobilization to decrease tension, the left colic artery needs
A leak after colon anastomosis contributes a large to be ligated close to its takeoff to preserve the collateral vessels.
amount of morbidity to the postoperative course. It most Care needs to be taken not to injure the ligament of Treitz and
often requires a drainage procedure or a second operation the tail of the pancreas.
necessitating creation of a temporary colostomy.2729
Grade 35 complication
Repair
Clinical suspicion of a leak justies reexploration in the
operating room. If inspection of the anastomosis reveals
a defect in the suture or staple line, reinforcing sutures
can be placed. Most of the time, however, a proximal
diverting ostomy will need to be created.14,28,29
Occasionally, patients can develop a subclinical leak
detected on routine contrast enema or on work-up for
fevers or leukocytosis. If there are no associated peritoneal
signs, these leaks can be treated expectantly or with a
percutaneous drainage procedure.14,27
Prevention
Many local and systemic factors are believed to contrib-
ute to an increased rate of anastomotic leak. Maintain- Figure 247 Make sure that not too much of the mesentery is
ing blood supply to the site of anastomosis is important. cleared prior to the anastomosis. Vigorous stripping of the mesen-
This ensures the viability of adjacent bowel. If an tery will result in ischemia that can lead to an anastomotic leak.
extended left colectomy needs to be completed, the left The mesentery should be cleaned sufciently so that the anasto-
motic site is free of thick, mesenteric fat.
colic artery may need to be ligated. This should be
done as close as possible to the takeoff from the inferior
mesenteric artery (Fig. 246). This retains the marginal end should be dbrided to provide a space sufcient for
blood supply and helps to keep the area at risk well anastomosis without incorporating any fat1,30 (Fig. 247).
vascularized. To conrm intact blood supply, I often Too much clean out will cause devascularization, which
use intraoperative Doppler to assess adequate signals by needs to be avoided. A hand-sewn anastomosis is generally
the proximal margin. Most literature supports the fact performed using 3-0 or 4-0 long-term absorbable sutures.
that an anastomosis performed with either single-layer A generous amount of the seromuscular layer is incorpo-
interrupted sutures or staples will preserve blood rated with a minimal amount of mucosa. This functions
supply.1 Another factor shown to contribute to leak is to invert the suture line. A single layer is adequate;
tension on the anastomosis. Normally, the transverse however, some surgeons may choose to add a second layer
colon should be adequately mobilized in order to be of Lembert sutures for reinforcement.14 Typically, inter-
anastomosed to the sigmoid without tension. If rupted sutures are used; however, use of a running stitch
the colon does not appear to reach, further mobiliza- has been shown to be just as effective.31 For stapled anas-
tion should be performed. tomosis, an appropriate-sized EEA stapler should be
After the colon has been divided, the ends must be chosen. The largest size should be used whenever possible
prepared for anastomosis. One centimeter to 2 cm of each so as not to create a functional stenosis.14 Once the
 270 SECTION III: GASTROINTESTINAL SURGERY
anastomosis is complete, two complete doughnuts should
be veried. Although circular staples are used frequently
in colorectal surgery, this method has not been proved to
be better than sutured anastamoses.32
Some preventive measures are employed by many
surgeons to protect the suture or staple line. Removal of
blood and cellular debris from the pelvis to avoid hema-
toma formation has been recommended.33 However,
other methods including prophylactic drainage and omen-
toplasty have not been shown to reduce the rate of anas-
tomotic dehiscence.34,35
In patients with systemic factors affecting the healing
process or in a technically difcult anastomosis, some may
choose to perform a temporary diverting ostomy to protect
the suture line. This does not reduce the rate of anasto-
motic leak but can reduce mortality rate.34
Other Complications
Bowel Injury
Accidental bowel injury is a recognized complication
with any intra-abdominal procedure. Most laparoscopy-
induced bowel injuries are recognized intraoperatively and
can be repaired immediately. However, 10% of injuries are
missed and are recognized during the postoperative
course. Most missed injuries are secondary to electrocau-
tery and blind trocar insertion. Less frequently, grasping
forceps and scissors are the cause. Injuries that are over-
looked are associated with a mortality rate of approxi-
mately 3.6%.5,36
If injuries are identied intraoperatively, conversion to
lapartotomy is often necessary. Most injuries including
serosal damage from electrocautery can be repaired with
simple suturing. Less often, bowel resection with reanas-
tomosis and proximal diverting ostomy is required.36
Inadvertent bowel injuries can be prevented in several
ways. Similar to the prevention of other injuries, using the
Hasson technique to gain access to the abdomen is judi-
cious. Furthermore, it is important to diligently follow
movements of the electrocautery and sharp dissecting
instruments with the camera in order to avoid damage
occurring out of view.36
Conversion to Open Procedure
During any laparoscopic procedure, conversion to the
open approach is an accepted risk. A reasonable conver-
sion rate is approximately 10% to 20%.5,7,9 However, this
varies with experience of the operating surgeon. Conver-
sion to an open procedure should be performed if there
is difculty with technical aspects of the procedure includ-
ing adequate exposure, mobilization of the bowel, and
identication of the ureters.6 In addition, if there are ana-
tomic issues that preclude safe dissection such as meta-
static tumor or excessive adhesions, laparotomy should be
considered. Finally, as discussed previously, inadvertent
injury to the ureter, bowel, or vessels supports modifying
the procedure to the open approach.5,37
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1. Condon RE. Resection of the colon. In Zuidema GD
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Philadelphia: WB Saunders, 1996; pp 207224.
2. Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis
and recurrent colonic diverticulitis. Am J Surg 1986;151:
269271.
3. Thaler K, Baig MK, Berho M, et al. Determinants of
recurrence after sigmoid resection for uncomplicated
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385388.
4. Fazio VW, Marchetti F, Church M, et al. Effect of
resection margins on the recurrence of Crohns disease in
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5. Regadas FS, Rodrigues LV, Nicodemo AM, et al.
Complications in laparoscopic colorectal resection: main
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192.
6. Hong D, Lewis M, Tabet J, Anvari M. Prospective
comparison of laparoscopic versus open resection for
benign colorectal disease. Surg Laparosc Endosc Percutan
Tech 2002;12:238342.
7. Clinical Outcomes of Surgical Study Group. A comparison
of laparoscopically assisted and open colectomy for colon
cancer. N Engl J Med 2004;350:20502059.
8. Patankar SK, Larach SW, Ferrara A, et al. Prospective
comparison of laparoscopic vs. open resections for
colorectal adenocarcinoma over a ten-year period. Dis
Colon Rectum 2003;46:601611.
9. Tekkis PP, Senagore AJ, Delaney CP, Fazio VW. Evalua-
tion of the learning curve in laparoscopic colorectal
surgery: comparison of right-sided and left-sided resec-
tions. Ann Surg 2005;242:8391.
10. Elliott SP, McAninch JW. Ureteral injuries: external and
iatrogenic. Urol Clin North Am 2006;33:5566, vi.
11. Fry DE, Milholen L, Harbrecht PJ. Iatrogenic ureteral
injury. Options in management. Arch Surg 1983;118:
454457.
12. Dowling RA, Corriere JN Jr, Sandler CM. Iatrogenic
ureteral injury. J Urol 1986;135:912915.
13. Lask D, Abarbanel J, Luttwak Z, et al. Changing trends in
the management of iatrogenic ureteral injuries. J Urol
1995;154:16931695.
14. Corman ML (ed). Carcinoma of the colon. In Colon and
Rectal Surgery. Philadelphia: Lippincott Williams &
Wilkins, 2005; pp 804856.
15. Walsh PC, Wein AJ, Kavoussi LR, et al. Surgical anatomy
of the retroperitoneum, kidneys, and ureters. In Kabalin J
(ed): Campbells Urology, 8th ed. Philadelphia: Saunders,
2002; p 7.
16. Bongard F. Thoracic and abdominal vascular trauma.
In Vascular Surgery. Philadelphia: WB Saunders, 2005;
pp 886887.
17. Barbosa Barros M, Lozano FS, Queral L. Vascular injuries
during gynecological laparoscopythe vascular surgeons
advice. Sao Paulo Med J 2005;123:3841.
18. Guloglu R, Dilege S, Aksoy M, et al. Major retroperito-
neal vascular injuries during laparoscopic cholecystectomy
and appendectomy. J Laparoendosc Adv Surg Tech A
2004;14:7376.
 24 LEFT COLECTOMY: OPEN AND LAPAROSCOPIC
19. Usal H, Sayad P, Hayek N, et al. Major vascular injuries
during laparoscopic cholecystectomy. An institutional
review of experience with 2589 procedures and literature
review. Surg Endosc 1998;12:960962.
20. Dixon M, Carrillo EH. Iliac vascular injuries during
elective laparoscopic surgery. Surg Endosc 1999;13:1230
1233.
21. Ignjatovic D, Djuric B, Zivanovic V. Is splenic lobe/
segment dearterialization feasible for inferior pole trauma
during left hemicolectomy? Tech Coloproctol 2001;5:23
25.
22. Langevin JM, Rothenberger DA, Goldberg SM. Acciden-
tal splenic injury during surgical treatment of the colon
and rectum. Surg Gynecol Obstet 1984;159:
139144.
23. Varty PP, Linehan IP, Boulos PB. Does concurrent
splenectomy at colorectal cancer resection inuence
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24. Bochicchio GV, Arciero C, Scalea TM. The hemostat
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25. Killingback M, Barron P, Dent O. Elective resection and
anastomosis for colorectal cancer: a prospective audit of
mortality and morbidity 19761998. Aust N Z J Surg
2002;72:689698.
26. Pickleman J, Watson W, Cunningham J, et al. The failed
gastrointestinal anastomosis: an inevitable catastrophe?
J Am Coll Surg 1999;188:473482.
27. Walker KG, Bell SW, Rickard MJ, et al. Anastomotic
leakage is predictive of diminished survival after potentially
curative resection for colorectal cancer. Ann Surg 2004;
240:255259.
28. Alves A, Panis Y, Pocard M, et al. Management of
anastomotic leakage after nondiverted large bowel
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271
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31. Burch JM, Franciose RJ, Moore EE, et al. Single-layer
continuous versus two-layer interrupted intestinal anasto-
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32. Fingerhut A, Hay JM, Elhadad A, et al. Supraperitoneal
colorectal anastomosis: hand-sewn versus circular staples
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33. Hirsch CJ, Gingold BS, Wallack MK. Avoidance of
anastomotic complications in low anterior resection of the
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34. Merad F, Hay JM, Fingerhut A, et al. Omentoplasty in
the prevention of anastomotic leakage after colonic or
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patients. French Associations for Surgical Research. Ann
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35. Merad F, Yahchouchi E, Hay JM, et al. Prophylactic
abdominal drainage after elective colonic resection and
suprapromontory anastomosis: a multicenter study
controlled by randomization. French Associations for
Surgical Research. Arch Surg 1998;133:309314.
36. van der Voort M, Heijnsdijk EA, Gouma DJ. Bowel injury
as a complication of laparoscopy. Br J Surg 2004;91:
12531258.
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outcome of laparoscopic surgery for colorectal cancers.
Dig Endosc 2005;17:191197.
25
Low Anterior Resection
Charles M. Friel, MD
INTRODUCTION
Surgical resection of all or part of the rectum with a
primary anastomosis is referred to as a low anterior resec-
tion. This procedure is most commonly performed for
rectal cancer. However, on occasion, the rectum is
removed for a variety of other benign and malignant con-
ditions. When done for mid and low rectal cancers, the
operation includes a total mesorectal excision1,2 with an
anastomosis at the level of the pelvic oor. For upper
rectal cancers, a partial mesorectal excision with a 5-cm
distal and mesorectal margin is probably adequate.3 In this
circumstance, the anastomosis is usually done in the
midrectum. When done for cancer, obtaining a negative
circumferential margin is critical to decrease the likelihood
of local recurrence.4,5 Therefore, the dissection must stay
outside the fascia propria and closer to the pelvic sidewall.
This may increase the likelihood of complications, includ-
ing bleeding and autonomic nerve injury. For benign
disease, there is no circumferential margin, so violation of
the fascia propria has no signicant implications. There-
fore, in benign disease, it is probably better to veer the
dissection closer to the rectum to decrease the probability
of these other complications. For the purpose of this dis-
cussion, it is assumed that the indication for surgery is
cancer and the technical points will stress adequate onco-
logic technique. These principles are generally applicable
to benign conditions as well. However, on occasion, there
are differences in patients with benign disease, and this is
noted in the text.
INDICATIONS
This is a partial list of surgical indications for a low ante-
rior resection. These procedures involve rectal resection
and a primary colorectal anastomosis.
The most common indication is
Upper, mid, and low rectal cancer
Other indications include
Large polyp not amenable to other techniques (e.g.,
endoscopy, transanal, transmission electron microscopy
[TEM])
Severe pelvic infection/inammation causing stricture
(e.g., radiation injury, pelvic inammatory disease,
rectal perforation, previous anastomotic leak)
Severe endometriosis
Upper rectal vaginal stulas
Other malignancies (e.g., ovarian cancer, retrorectal
tumors, rectal sarcomas)
OPERATIVE STEPS
Step 1 Positioning and incision
Step 2 Mobilization of sigmoid and left colon
Step 3 Takedown of splenic exure
Step 4 Ligation of vasculature
Step 5 Rectal mobilization
Step 6 Anastomosis
OPERATIVE PROCEDURE
Patient Positioning
Patients are placed in a modied lithotomy position to
perform a low anterior resection. This allows access to the
perineum for a stapled anastomosis. The patients arms are
usually extended to allow access for the anesthesiologist.
In addition, a self-retaining retractor is quite helpful for
exposure. Proper positioning of the patient and the retrac-
tor is critical to prevent iatrogenic nerve injuries.
Peripheral Nerve Injuries
Consequence
Clearly, the consequences of this complication depend
on the severity of the injury. Most peripheral nerve
injuries occur from prolonged compression or stretch.
Often, this is just neuropraxis and will resolve com-
pletely with time. Less commonly, permanent injury
can result that will leave a permanent disability.
Grade 1 complication (if resolves); grade 4 (if
permanent)
Repair
Generally, there is no operative repair for patients with
peripheral nerve injury from compression or stretch.
 274 SECTION III: GASTROINTESTINAL SURGERY
Figure 251 Self-retaining retractor. To prevent femoral nerve
injury, great care must be used when placing retractor blades
(marked with an X) in the inguinal region.
Treatment is just supportive, which would include
physical and occupational therapy.
Prevention
Careful patient positioning is key to prevent injuries.6
Well-padded stirrups are necessary. The patients heel
should be placed rmly in the foot of the stirrup so that
the weight of the leg is supported by the patients heel.
It is also helpful to tilt the stirrup posteriorly to prevent
pressure from being applied to the posterior and lateral
aspects of the lower extremity, which will aid in pre-
venting common peroneal nerve injury. This area can
be further padded if necessary. To prevent brachial
plexus injuries, the patients arms should rest easily and
should not be extended more than 90.6 Furthermore,
nothing should be placed between the shoulder blades
that can stretch the brachial plexus by elevating the
chest. The anesthesiologist and operating staff should
also monitor the position of the arms because they may
shift during the procedure, particularly if the patient is
placed in Trendelenburg position to gain additional
exposure. Finally, to prevent femoral injuries, great care
must be taken when utilizing a self-retaining retractor.7
Retractors over the inguinal region should be used with
caution, especially in thin patients (Fig. 251). How-
ever, if necessary, use the most supercial retractor
available (e.g., the bladder blade) (Fig. 252) because
deeper retractors are more likely to compress the
femoral nerve, which runs just beneath the psoas
muscle. If the operation is prolonged, periodically
release and replace the retractors to limit the potential
for prolonged compression to an isolated spot. If a
perineal approach is necessary at any time, take care to
remove the abdominal wall retractors as well. This
injury is more common with a transverse incision,
which is being utilized more frequently as surgeons
adopt a laparoscopy-assisted approach to rectal surgery.
Figure 252 Examples of self-retaining retractors. Arrow identi-
es the retractor with the least depth and, therefore, the least likely
to damage the femoral nerve.
Incision
Most low anterior resections can be accomplished through
a midline incision. Exposure is critical to safely complete
all portions of the procedure. To properly expose the
pelvis, the incision frequently needs to go all the way to
the pubis. This will allow the best visualization of the deep
pelvic structures. For most low anterior resections, com-
plete mobilization of the splenic exure is also necessary.
Therefore, the upper extent of the incision is often well
above the umbilicus. In patients who are thin or have a
low splenic exure, the incision may need to extend only
to the umbilical region. It is best to start with a lower
midline incision and then extend as necessary to gain the
required exposure.
Bladder Injury
Although rare, iatrogenic injuries to intra-abdominal
structures can occur while the abdomen is being opened.
Clearly, these injuries are more likely to occur in patients
who have had previous abdominal surgery. However,
when doing a low anterior resection, special consideration
should be given to the lower portion of the incision. While
extending to the pubis, an injury to the dome of the
bladder is possible and care must be taken to avoid this
problem.
Consequence
Fortunately, an injury to the bladder while making an
incision is usually in the bladder dome. This is generally
readily apparent and can be promptly xed. When this
is done, there are few long-term consequences, except
for prolonged catheterization. An unrecognized injury
will lead to an intra-abdominal urine leak and can result
in sepsis. Repair is also greatly complicated and will
require long-term bladder drainage.

Bleeding
Figure 253 Opening incision. To avoid bladder injury, incise the
anterior fascia all the way to the pubis, staying anterior to the
underlying muscle.
Grade 2 complication (if recognized); grade 3 com-
plication (if not recognized)
Repair
The bladder dome is easily repaired and generally for-
giving. Closure of the defect is generally done in two
layers with an absorbable suture. Permanent suture is
avoided to prevent future calculi and granulomas. To
keep the bladder decompressed, a Foley catheter is
generally kept for approximately 7 to 10 days.8
Prevention
When opening the abdomen, it is important to get all
the way to the pubis for proper pelvic exposure.
However, most of the benet is from incising the ante-
rior fascia. The bladder will lie beneath the pyramidalis
and rectus muscles. Therefore, if the dissection is always
above these muscles, the bladder cannot be injured
(Fig. 253). Division of the posterior peritoneum is not
always necessary in this region because it is easily
retracted with a self-retaining retractor. If division of
this peritoneum is necessary, it can be done carefully
layer by layer to identify the bladder dome. Further-
more, the dissection of the peritoneum can veer a bit
off midline, which will help avoid the bladder dome.
Colon Mobilization and Ligation of
the Mesenteric Vessels
In order to perform a low anterior resection of the rectum,
the sigmoid colon must be fully mobilized. Furthermore,
in most instances, complete mobilization of the descend-
ing colon and splenic exure is also required to perform
a tension-free anastomosis (see later). Most mishaps that
can occur during this portion of the procedure are similar
for any left-sided colonic operation and are well described
in Chapter 24 (Left Colectomy: Open and Laparoscopic).
These complications are briey reviewed here.
25 LOW ANTERIOR RESECTION 275
Consequence
If the proper planes are found and dissected properly,
bleeding from colonic mobilization should not be
signicant. When bleeding is encountered, the surgeon
should question whether he or she is in the proper
plane and adjust accordingly. Most bleeding is easily
controlled without any signicant sequelae. Some evi-
dence suggests that patients who get a blood transfu-
sion are more likely to have a cancer recurrence and/or
an infectious complication of surgery.911 Whether this
is due to the immunosuppression of the transfusion or
is just a marker for a difcult case has not been deter-
mined.12,13 Nevertheless, to prevent the unnecessary
risk of a blood transfusion, bleeding should be kept to
a minimum whenever possible.
Grade 1 complication
Repair
Identication and ligation are all that is necessary for
proper control of bleeding. If necessary, the gonadal
vessels can be ligated once the ureter is clearly identi-
ed. Bleeding from the major vascular structures, such
as the aorta or iliac vessels, is unusual but can be
directly repaired after proper proximal and distal
control.
Prevention
Proper identication of the avascular planes is necessary
to prevent unnecessary bleeding. The descending colon
and its mesentery lie just anterior to the retroperito-
neum and its associated structures. An areolar plane
exists between the mesocolon and the retroperitoneum
and, when dissected, allows the colon and the mesoco-
lon to be fully mobilized to the midline position. The
dissection is begun by dividing the lateral peritoneum
of the sigmoid and descending colon. Rapid identica-
tion of the gonadal vessels can be quite helpful because
these vessels are the most anterior of the retroperitoneal
structures and should be swept posteriorly off the
colonic mesentery (Fig. 254). Care must be taken to
stay above the gonadal vessels because they are quite
fragile and will bleed with too much manipulation.
However, when this plane is properly identied, there
should be little bleeding; if this plane is followed, the
colon and the mesocolon should be lifted off the left
kidney to prevent inadvertent kidney mobilization. As
the gonadal vessels are swept posteriorly, the mesoco-
lon and, specically, the inferior mesenteric vessels are
elevated to a midline position. The ureter, which passes
beneath the gonadal vessels, can be identied as it
crosses the iliac vessels. Once the gonadal vessels and
kidney have been swept posteriorly, the peritoneum on
the right-hand side should be divided just at the sacral
promontory and underneath the superior rectal artery.
This will allow entrance into the retrorectal space,
which is also avascular. This dissection should meet the
 276 SECTION III: GASTROINTESTINAL SURGERY
Figure 254 Dissection of the gonadal vessels off the mesentery
of the colon. This plane is avascular and will guide the surgeon
to the plane separating the colon and its mesentery from the
retroperitoneum.
B
previous dissection on the left-hand side and create a
window under the superior rectal artery (Fig. 255).
The superior rectal artery can then be further dissected
on the right-hand side all the way to the aorta, where
it is now the inferior mesenteric artery (IMA). If the
dissection on the left-hand side was done properly, the
gonadal vessels and ureter should be easily visualized
from the right-hand side underneath the IMA. An avas-
cular window can now be identied through the meso-
colon on the left-hand side of the IMA. The inferior
mesenteric vein (IMV) is just to the left of the IMA
and can be dissected out separately. Care should be
taken to identify the duodenum, which should be
located just superior to the IMA (Fig. 256). Once
these vessels are properly identied, they can be divided
and doubly ligated (Fig. 257). It is advisable to leave
a stump for the IMA in case vascular control is lost.
Reclamping and ligating the base of the IMA is con-
siderably easier than repairing a defect in the aorta.
Figure 255 Mesentery of rectosigmoid colon
from the right-hand side. A, Line shows the
approximate course of the superior rectal artery.
Shaded area represents avascular window poste-
rior to the superior rectal artery at the level of
sacral promontory. B, Avascular window is opened,
posterior to the superior rectal pedicle.

Figure 256 Position of the duodenum in rela-
tion to the pedicle of the inferior mesenteric
vessels. Yellow shows the approximate location of
the inferior mesenteric artery (IMA). Note that
the peritoneum to the left of the IMA has been
incised and the IMA is being lifted off the aorta by
the left dissecting hand.
A
B important to remember several principles. The ureter runs
Figure 257 Inferior mesenteric vessels are identied and
clamped (A) and then ligated (B). Forceps point to the ureter
and the retroperitoneum, which have been swept posteriorly (A).
Note the proximity of the ureter to the inferior mesenteric vessels
at the point of ligation (B).
25 LOW ANTERIOR RESECTION 277
Great care with the IMV is also critical because this
vessel is prone to retract underneath the pancreas,
which will make vascular control quite difcult once it
is lost. This describes a high ligation of the IMA and
IMV. From an oncologic perspective, this may not
be necessary,14 and division of the IMA and IMV
can be done together with a single clamp just distal to
the takeoff of the left colic artery. However, for a very
low anastomosis, division of these vessels is often
required to provide the necessary colonic length to do
a safe, tension-free anastomosis (see the section on
Anastomosis).
Ureteral Injury
An intra-abdominal injury to the ureter is possible when
the sigmoid and descending colon is mobilized. This is
fully described elsewhere in the text so it is only reviewed
here. Clearly, proper identication of the ureter is essential
to preventing injuries. The ureter is usually identied as
it crosses the iliac vessels but must be followed superiorly
and swept posteriorly to prevent injury when ligating the
IMA and IMV. It is important to remember that the
ureter lies beneath the gonadal vessels, so if the dissection
is above the gonadal vessels, the ureter should also be
posterior and out of harms way. Sometimes, the ureter is
difcult to clearly identify and is most often confused with
the gonadal vessels. Under these circumstances, it is
longitudinally through the retroperitoneum. It never
branches, as do blood vessels, and when manipulated, it
should show evidence of peristalsis (Fig. 258). If the
ureter cannot be identied secondary to inammation or
tumor, the ureter should be identied higher in the
abdomen, where the anatomy may be more normal, and
followed distally. If it is anticipated that ureteral identica-
 278 SECTION III: GASTROINTESTINAL SURGERY

Figure 258 Retroperitoneum after dissection

and removal of the rectum and associated lymphat-
ics. Note the direction of the ureter, which is
parallel to the aorta, compared with the gonadal
vessels, which veer laterally. Also note that the
ureter passes beneath the gonadal vessels.

tion will be difcult, placing ureteral stents preoperatively

can be quite helpful.
Grade 2 complication

Splenic Injury
When the splenic exure is mobilized, the spleen can be
injured and cause troublesome bleeding.15 This complica-
tion is possible with any intra-abdominal colon operation
and is reviewed in detail elsewhere. Most splenic injuries
originate from omental attachments to the splenic capsule.
With downward retraction on the colon, these attach-
ments are torn off the splenic capsule, causing bleeding
from the injured spleen. Fortunately, these attachments
are unusual, but when identied, they need to be carefully
divided (Fig. 259). If the splenic exure is torn, trouble- A
some bleeding will ensue. Most of the time, this bleeding
is well controlled with simple packing, but on occasion,
bleeding will persist. Although other maneuvers to con-
trol bleeding are available, the surgeon should not hesi-
tate to perform a splenectomy if the bleeding is not well
controlled.
Grade 1/2 complication

Rectal Mobilization
An understanding of rectal anatomy is critical to proper
rectal mobilization. The rectum is surrounded by a large
amount of fat containing the mesentery and lymphatics to
the rectum itself. This tissue is enveloped by a thin layer
of fascia, known as the fascia propria. An avascular plane
exists between the fascia propria and the presacral fascia, B
which is adherent to the periosteum of the sacrum. The Figure 259 Omental attachments to the spleen (A), which
retrorectal fascia, or Waldeyers fascia, is a thick layer of needs to be divided (B) to prevent injury to the spleen with down-
fascia connecting the presacral fascia to the fascia propria ward retraction of the colon.
of the rectum. Division of this fascia is necessary to mobi-
lize the distal rectum, and when divided, the rectum will
lift from the sacral hollow and begin a more anterior

approach. This greatly lengthens the rectum, especially
posteriorly. For this reason, a low-lying posterior tumor
may elevate signicantly after division of the retrorectal
fascia, allowing for a low anterior resection. Anteriorly,
the rectum is more xed and will not lengthen as much
with mobilization. Therefore, a low-lying anterior tumor
will more likely require an abdominal perineal resection
than would a posterior-based tumor at the same preop-
erative level.
Rectal mobilization begins by entering the retrorectal
space at the level of the sacral promontory (see Fig. 255).
Division of the peritoneum at this level will identify the
avascular plane between the mesorectum and the presacral
fascia. The peritoneum lateral to the rectum is then incised
toward the anterior cul-de-sac bilaterally. Finally, the ante-
rior peritoneum also needs to be divided, which will allow
entrance into the proper plane to mobilize the vagina in
a woman, or the seminal vesicles and prostate in a man.
Once the peritoneum is completely incised, the rectum is
further mobilized by dividing the areolar tissue that exists
between the fascia propria of the rectum and the fascia of
the pelvic sidewall, collectively referred to as the endopel-
vic fascia. This dissection is greatly facilitated by proper
deep pelvic retractors and anterior retraction of the rectum
(Fig. 2510). This dissection should be continued poste-
riorly and in the midline as deep as possible (Fig. 2511).
This will help identify the proper lateral plane, which
should continue just adjacent to the mesorectum. Finally,
the anterior plane needs to be developed, separating either
the vagina or the prostate from the rectum (Figs. 2512
and 2513). This is greatly facilitated by using a lipped
pelvic retractor and anterior traction on the vagina or
prostate while using the hand for posterior traction of the
rectum. Whereas this description implies that the poste-
rior, lateral, and anterior dissections are done sequentially,
in reality the surgeon needs to constantly adjust her or his
retractors to dissect the area that is currently best exposed
and continue this dissection circumferentially all the way
to the pelvic oor. When this is done properly, there
should be no mesorectum at the pelvic oor, thus com-
Figure 2510 Deep pelvic retractors.
25 LOW ANTERIOR RESECTION 279
pleting a total mesorectal excision. Therefore, all that
should be left is the rectum itself as it enters the rectal
ampulla between the muscles of the pelvic oor. Division
of the rectum at this level can almost always be done with
one re of a 30-mm transverse stapling device. Figure
2514 shows the nal appearance of the sacral hollow
after complete removal of the rectum and the associated
mesorectum.
Hemorrhage
Although uncommon, massive and life-threatening bleed-
ing can be encountered with rectal mobilization. This is
most commonly from the presacral plexus and can occur
when the presacral fascia is injured. Bleeding is venous in
nature and can be quite profuse. The bleeding source is
from either the veins just below the presacral fascia or the
basivertebral veins, which are within the sacrum itself.
The basivertebral veins, when injured, will retract within
the sacral foramen and can be extremely difcult to
control. Other sources of major pelvic bleeding include
the vessels of the pelvic sidewall, the most signicant being
the internal iliac artery and vein.
Consequence
Signicant and even life-threatening bleeding can occur
from either the presacral plexus or the internal iliac
vessels. In general, signicant venous bleeding is more
difcult to control, due partly to the poor exposure of
these venous structures and to the nature of their thin
walls, which can tear easily and cause more excessive
bleeding. Clearly, massive blood loss can be immedi-
ately life-threatening. But even if controlled, this
complication can lead to continued postoperative pro-
blems, including multisystem organ failure and delayed
death.
Grade 2 complication (if quickly controlled); grade
4 complication (if not controlled quickly)
Repair
When profuse bleeding is initially encountered, direct
pressure is most appropriate. Because venous bleeding
is low, this pressure will quickly control the signicant
blood loss. Prolonged pressure may in fact stop the
bleeding but will at least allow the anesthesiologist time
to get proper access and blood products available. To
the surgeon, the bleeding may only seem brisk, but
it is important to remember that blood loss of 100 ml/
min will result in a 1-L blood loss in only 10 minutes
and can quickly lead to patient instability. If the bleed-
ing appears to be coming from the presacral veins, no
attempt should be made to dissect this further, because
this generally results in more signicant bleeding.
Suture ligation can be quite tempting but often further
disrupts the presacral fascia, potentially exposing the
sacral foramina and the basivertebral veins, resulting in
worsening bleeding.16 Direct pressure and utilization
of any variety of hemostatic products can be used
280 SECTION III: GASTROINTESTINAL SURGERY

Ureter

Figure 2511 Posterior dissection. A, Pelvic

retractor provides anterior retraction on the
rectum. Yellow line shows the approximate plane
of dissection, dissecting the mesorectum from
the sacral hollow using either sharp dissection
or electrocautery. B, Retrorectal (Waldeyers)
fascia in the deep posterior midline. Rectum is
anteriorly retracted and not visible. Yellow line
shows the approximate plan of dissection, which
is done sharply or with electrocautery to minimize
B
bleeding.

Figure 2512 Anterior dissection in a male.

Pelvic retractor provides anterior retraction on
the seminal vesicles and prostate while the hand is
pushing the rectum posteriorly, exposing the ante-
rior cul-de-sac. Straight arrow shows the point of
dissection. Denonvilliers fascia is the white tissue
just posterior to the line of dissection, denoted by
curved arrow.

A
B be ligated without signicant sequelae. In these difcult
Figure 2513 Anterior dissection in a woman with a previous
hysterectomy. A, Lateral peritoneum has already been incised.
Entrance to the rectovaginal septum is obtained by dividing the
peritoneum anteriorly, along the dotted line. B, Demonstration of
the rectal stump, after the rectum has been removed, shows the
posterior vaginal wall. The rest of the vagina is being retracted
anteriorly.
25 LOW ANTERIOR RESECTION 281
Figure 2514 Sacral hollow after completion of low anterior
resection and simultaneous hysterectomy and oopherectomy,
shows complete removal of the sigmoid and rectal mesentery, the
position of the left ureter and preservation of the hypogastric
nerves.
effectively.16,17 If this is not successful, sterile titanium
thumbtacks can be used to directly compress the bleed-
ing vein16,18 (Fig. 2515). As a last resort, the pelvis can
be packed and the patient taken to the intensive care
unit for 24 to 48 hours. The patient is then taken back
to the operating room and the packs removed. By that
time, the bleeding has usually stopped and the opera-
tion can be completed.
Bleeding from the internal iliac vessels is also uncom-
mon. It is most likely encountered with a large tumor
adherent to the vessels or with signicant pelvic scarring
from previous infection or radiation. For venous bleeding,
proximal and distal control is best accomplished with
sponge sticks and direct pressure.19 The vein lies behind
the artery, so exposure can be difcult. The vein can be
repaired directly if the injury is small and easily visualized.
If necessary, both the internal iliac artery and vein can
situations, an experienced vascular surgeon can be quite
helpful.19
Prevention
Presacral bleeding usually occurs if the presacral fascia
is disrupted. This is best avoided by using sharp dissec-
tion in the retrorectal space. Blunt dissection should be
discouraged. This is particularly true when dividing the
retrorectal fascia (Waldeyers fascia), which is often very
 282 SECTION III: GASTROINTESTINAL SURGERY

tough tissue and is adherent to the presacral fascia (see

Fig. 2511B). Attempts to bluntly dissect through this
tissue are more likely to disrupt the presacral fascia and
lead to bleeding. To prevent bleeding from the pelvic
sidewall, including the internal iliac vessels, careful dis-
section should be done just adjacent to the fascia
propria of the rectum. Whereas for oncologic reasons,
it is important to keep the fascia propria intact, if the
dissection is done too laterally, troublesome bleeding
can be encountered. Occasionally, the dissection must
be done more laterally to get circumferential tumor
clearance. Under these circumstances, the surgeon
should clearly identify the iliac vessels, including the
bifurcation of the internal and external iliac vessels, well
above the tumor and be prepared to intervene if bleed-
ing from these vessels ensues.

A Sexual and Bladder Dysfunction

Both sympathetic and parasympathetic nerves can be
damaged with rectal surgery. The sympathetic bers begin
in the aortic plexus near the IMA. These bers coalesce
to form two main hypogastric nerves, which are readily
identiable at the level of the sacral promontory (Fig.
2516; see also Fig. 2514). These nerves carry sympa-
thetic innervation to the pelvic plexus. Parasympathetic
innervation is supplied by the nervi ergentes, which pass
through the sacral foramen and run laterally and then
forward to also join the pelvic plexus. The pelvic nerves
tend to be lateral, near the pelvic sidewall, but will course
anteriorly as they approach the prostate and seminal ves-
icles, forming the periprostatic plexus. Although the two
main hypogastric nerves can be readily seen during surgery,
most nerve bers are not identiable and knowledge of
B their location is necessary to minimize nerve injury.
Figure 2515 A, Sterile thumbtacks and applicator. B, Close up
of sterile thumbtacks.

Figure 2516 Position of hypogastric nerves.

Forceps point to the trunks of the hypogastric
nerves.

Consequence
Injury to the sympathetic and parasympathetic nerves
can cause both bladder and sexual dysfunction. Whereas
the incidences of bladder and sexual dysfunction are
reportedly similar, to most clinicians, sexual dysfunc-
tion seems more common and problematic. This is
probably related to the observation that minor changes
in bladder dysfunction may not be as readily apparent
as sexual dysfunction to the clinician. Sexual dysfunc-
tion in men can be either the inability to have an erec-
tion or the failure to ejaculate uid despite achieving
orgasm and are related to different types of neural
injuries.20 Woman may experience dyspareunia after
rectal surgery. Bladder dysfunction can present as
urgency, dribbling, leaking, or the inability to com-
pletely void.20 All of these problems are considerably
more common as patients get older and are probably
related to both aging and the use of concomitant radi-
ation commonly employed for the treatment of rec-
tal cancer.20,21 It is important to discuss these issues
with patients prior to surgery and to get a good under-
standing of their preoperative sexual and urologic func-
tion, because sexual and urologic dysfunction is quite
common, especially as people get older.21
Grade 2/4 complication
Repair
No surgical repair exists for nerve injuries during
rectal surgery. Some problems with bladder and sexual
dysfunction will improve with time.22 The treatment
is symptomatic. Continued bladder dysfunction will
require either prolonged catheterization or a self-
catheterization program. For patients with persistent
sexual dysfunction, both medical and surgical options
exist to improve potency, and a urologic consultation
is warranted.
Prevention
Precise dissection is the best way to prevent nerve inju-
ries.20,22 When the IMA is ligated, care should be taken
to stay right underneath the vessel because the nerves
tend to course over the aorta. The hypogastric nerves
can usually be seen right at the sacral promontory and
begin to sweep laterally. Gaining access to the retrorec-
tal space right in the midline is less likely to damage
these nerves. Dissection should be right on the fascia
propria, which will ensure that the dissection is anterior
to these nerves. Frequently, the hypogastric trunks will
be adherent to the fascia propria, and they need to be
carefully dissected off and swept laterally. To further
minimize injury to the pelvic nerves, care should be
taken to stay just adjacent to the fascia propria of the
rectum because the nerves tend to be closer to the
pelvic sidewall. This is true for the entire rectal dissec-
tion, but it is most important during the anterior lateral
dissection near the seminal vesicles. Precise dissection
is critical to best preserve nerve function while doing
an oncologically appropriate operation. Clearly, for
25 LOW ANTERIOR RESECTION 283
benign disease, it is best to veer closer to the rectum
to help further decrease the likelihood of permanent
nerve injury.
Anastomosis
Anastomotic Leak
Anastomotic leak is the dreaded complication associated
with colon and rectal surgery and is the most common
cause of death after an elective colon or rectal resection.
For rectal surgery, the incidence can vary from approxi-
mately 3% to 10%, depending on the level of the ana-
stomosis. Very low pelvic anastomoses will leak more
frequently than those performed to the midrectum.3,23
Other factors contributing to a higher leak rate include
pelvic radiation, male gender, and prolonged surgery,23
which is most likely a surrogate for a difcult operation.
The clinical presentation of an anastomotic leak can be
quite varied. Whereas some leaks will present as frank
peritonitis, others can be more subtle, such as a pelvic
abscess. The diagnosis must be suspected in any patient
who has a new rectal anastomosis and has a cardiopulmo-
nary collapse of an unclear etiology. Failure to promptly
make this diagnosis will contribute to ongoing sepsis and
will likely lead to a poor outcome.
Consequence
The clinical consequences of an anastomotic leak
depend on the severity of the leak itself. For small leaks
resulting in a pelvic abscess, a percutaneous drain may
be all that is necessary, with little long-term signi-
cance. However, a leak associated with fecal peritoni-
tis is clearly life-threatening. It generally will require
a reoperation and the creation of a diverting stoma.
Intensive care monitoring is often required to deal with
the septic sequelae of the leak. Once a patient does
recover, restoration of intestinal continuity may be
compromised. Some patients will have a permanent
stoma, whereas others will be reversed but brosis will
result in an anastomotic stricture or poor function. In
addition to these complications, data also suggest that
local/regional cancer recurrence rates are higher in
patients who have had an anastomotic leak.24,25
Grade 2/4/5 complication
Repair
If a patient has a well-contained leak without evidence
of systemic illness, percutaneous drainage is appropriate
and often successful. For patients who do not improve
with catheter drainage or those who are systemically ill
at presentation, operative management is warranted.
Reexploration after an anastomotic leak can be very
challenging, because the adhesions can be quite dif-
cult, especially near the leaking anastomosis. If the
anastomosis can be readily identied and there is a large
dehiscence, resecting the anastomosis and creating an
end colostomy are appropriate. However, the anasto-
mosis frequently cannot be easily seen. Under these
 284 SECTION III: GASTROINTESTINAL SURGERY
circumstances, extensive dissection can be troublesome
and should be avoided. Pelvic drainage and proximal
diversion, with either a loop colostomy or an ileostomy,
can be done.26 Whereas some authors have expressed
concern about ongoing sepsis from a stool-lled colon,
recent evidence suggests that sepsis can be well con-
trolled with proper drainage and proximal diversion.26
Furthermore, with this approach, many low-lying anas-
tomoses that have leaked can be salvaged, thus increas-
ing the likelihood of restoring intestinal continuity.
Occasionally, a small leak is easily visualized. Under
these circumstances, simple repair of the anastomosis is
quite tempting. However, this approach is frequently
unsuccessful, and the consequences of a second leak are
usually devastating. Therefore, simple closure without
proximal diversion should be discouraged.
Prevention
Proper construction of a low-lying anastomosis is crit-
ical to minimize the likelihood of an anastomotic leak.
For an anastomosis to properly heal, healthy bowel
must be available on either end of the anastomosis in
addition to a good blood supply and no signicant
tension. For a low pelvic anastomosis, complete mobi-
lization of the splenic exure is almost always required.
However, even after all the avascular retroperitoneal
attachments are divided, it still can be difcult to get
the descending colon to reach the pelvic oor. Under
these circumstances, the colon is still tethered by the
colonic mesentery. Therefore, in order to get the nec-
essary length, either the IMA needs to divided at the
aorta or the left colic vessel is divided just as it branches
off the IMA (see Fig. 257). Great care must be taken
not to damage the marginal artery, which runs parallel
to the colon and only a few centimeters from the mes-
Figure 2517 Fully mobilized descending colon,
which will easily reach low in the pelvis. Yellow line
shows the approximate location of the marginal
artery, which must be carefully preserved to provide
adequate blood supply to the mobilized colon.
enteric border of the colon (Fig. 2517). Once the
IMA or left colic artery is ligated, the entire blood
supply to the left colon is from the middle colic artery
via the marginal artery. If, after dividing the arterial
blood supply, there is still tension, the IMV should also
be divided near the duodenum and pancreas. Once this
is done, the avascular portion of the colonic mesentery
can be divided all the way to the middle colic vessels,
and the colon will have plenty of length to reach the
pelvic oor (see Fig. 2517). Furthermore, as long as
the marginal artery is not damaged, blood supply to
the distal descending colon will be adequate. An under-
standing of this anatomy and faith in the marginal
artery are paramount to constructing a proper low anas-
tomosis without tension and with good blood supply.
The last factor, ensuring healthy ends of bowel, is
usually not problematic with good tissue handling.
However, because more patients receive preoperative
radiation for rectal cancer, the distal bowel is not
normal, which may impair proper healing.
All distal anastomoses should be thoroughly evaluated
by rst examining the integrity of the anastomotic dough-
nuts and then by air insufation. If a leak is identied,
attempts at suture repair are warranted. If, as is frequently
the case, the anastomosis cannot be visualized, large leaks
may, under some circumstances, be repaired via a transanal
approach. Small leaks that cannot be repaired are best
treated with proximal diversion and drainage. Under most
circumstances, these small leaks will seal on their own and
the ostomy can be reversed at a later date.
Debate continues about whether a low-lying anastomo-
sis should be routinely protected by proximal diversion.
Critics of proximal diversion correctly assert that diversion
itself does not prevent an anastomotic leak.27 Further-
more, there is associated morbidity from the reversal of
 25 LOW ANTERIOR RESECTION 285

the proximal stoma. However, proponents of proximal

diversion will note that in most series a low rectal anasto-
mosis will leak approximately 10% of the time3,28 and that,
although diversion does not prevent an anastomotic leak,
the clinical consequences of the leak are greatly dimin-
ished in patients who are proximally diverted.23,28,29 There-
fore, proximal diversion should be strongly considered for
any patients who have had previous radiation, who have
a low anastomosis, if there is any concern about the integ-
rity of the anastomosis, or who cannot medically tolerate
the signicant morbidity of fecal peritonitis.23,28,29

Anastomotic Bleeding
Consequence
Clinically signicant bleeding from a colorectal anasto-
mosis occurs approximately 2% of the time. Fortu-
nately, most bleeding is self-limited and will stop on
it own accord.30 Very rarely, an intervention will be A
necessary.
Grade 1/2 complication
Repair
If a low-lying anastomosis does bleed, it is usually
readily apparent because blood will pass through the
rectum. Most bleeding is self-limited and will stop.30
Therefore, as long as the patient is hemodynamically
stable, support is all that is necessary. Occasionally, the
bleeding will be persistent and perfuse (Fig. 2518A).
Under these circumstances, it is best to attempt endo-
scopic management.31 A low-lying anastomosis is easily
seen with the colonoscope and the bleeding identied.
Bleeding can be frequently controlled with epinephrine
injection or with an endoscopically applied clip (see
Fig. 2518B). If this is unsuccessful or not available,
surgery will be necessary. For an anastomosis in the
upper rectum, simply overseeing the anastomosis may
be all that is necessary. For a very low-lying anastomo-
sis, stitches can be applied via a transanal approach. B
Redoing the anastomosis can be very difcult and
Figure 2518 A, Anastomotic bleeding. B, Treatment with
should be done only as a last resort. endoscopically applied endoclips.

Prevention
No good way exists to prevent anastomotic bleeding
for a low pelvic anastomosis.
Anastomotic Stricture
Consequence
A stricture can have an impact on bowel function. The
clinical impact depends on the severity of the stricture.
Obviously, for very tight strictures, evacuation will be
difcult and, on rare occasions, impossible. Many stric-
tures are mild and can be managed with a combination
of gentle dilation and bowel management, such as a
high-ber diet and stool softeners. More signicant
strictures will require either an endoscopic or a surgical
treatment.
Grade 1/2 complication
Repair
Only symptomatic strictures should be treated. Gener-
ally, these are in patients in whom, on endoscopic
examination, a standard colonoscope cannot be passed.
Once symptoms do occur, endoscopic management
should be attempted. This is usually accomplished with
balloon dilation and is frequently successful. For very
tight stenosis, the stricture can be partially pretreated
with electrocoagulation or an argon beam coagulator
prior to balloon dilation.32 Other options include self-
expanding colonic stents and endoscopic transanal
resections of strictures. However, the long-term results
of these latter approaches are still unclear.33 For very
tight or long strictures, operative management may
be necessary. This usually involves resection and the
 286 SECTION III: GASTROINTESTINAL SURGERY
creation of a new colorectal or coloanal anastomosis.
These operations are generally reserved for patients
with mid or upper rectal strictures and can be very
challenging.34 Temporary diversion after anastomotic
revision is almost always done. Patients with low-lying
strictures that cannot be managed with endoscopic
means may require a permanent colostomy for symp-
tomatic control.
Prevention
Many anastomotic strictures are associated with a clin-
ical anastomotic leak. Presumably, many of the other
strictures may be secondary to subclinical leaks,
although this is difcult to demonstrate. Prevention of
anastomotic strictures is, therefore, similar to that for
preventing anastomotic leaks. Proper anastomotic tech-
nique, with particular attention to lack of tension and
blood supply, is critical. Reportedly anastomotic stric-
tures are more common in stapled than in hand-sewn
anastomoses.35 An association also seems to exist
between fecal diversion and an increased stricture rate.36
However, the benets of diversion may outweigh the
risk of subsequent stricture.
Vaginal Injury and Rectal Vaginal Fistulas
Consequence
Injury to the vagina and subsequent rectovaginal stula
are uncommon but have been reported in the litera-
ture.37,38 Whereas some stulas result from direct injury
to the vagina, others develop from an anastomotic leak
and subsequent pelvic abscess.39 Symptoms will vary
depending on the size of the resulting stula. For
patients with minimal symptoms, observation and a
bowel-conning program may result in spontaneous
healing. If unsuccessful, operative management will be
necessary.
Grade 24 complication
Repair
If the vagina is injured during the operative procedure,
it can be repaired with nonabsorbable sutures. This may
require careful and additional development of the rec-
tovaginal septum to identify the injury. After the repair
is complete, it is advisable to place well-vascularized
omentum between the anastomosis and the vagina to
help prevent stula formation. Under these circum-
stances, proximal diversion may also be advised.
Once a rectovaginal stula is identied, it is critical to
identify the exact location of the stula. A high stula may
require further resection and the creation of a coloanal
anastomosis.39 A low-lying stula may be amenable to an
endorectal mucosal advancement ap39 or a ap using
either bulbocavernosus tissue or the gracilis muscle.
Results from these procedures may be impaired by previ-
ous pelvic radiation. Proximal diversion may be necessary
for symptomatic relief and may, in some situations, lead
to spontaneous healing.
Prevention
In order to perform a very low anastomosis, complete
mobilization of the rectovaginal septum is necessary.
This is facilitated by using a lipped pelvic retractor and
anterior retraction on the posterior wall of the vagina.
If the surgeon encounters troublesome bleeding, he
or she is usually too anterior and may risk injuring the
posterior vaginal wall, which will readily bleed. It is very
important to mobilize the vagina all the way to the
pelvic oor. This will completely separate the rectum
and vagina so that a stapler can be safely placed around
the rectum. When performing the end-to-end stapled
anastomosis, the pelvic retractor should elevate the
vaginal wall and the stapler should be lowered under
direct visualization, taking care that the posterior wall
of the vagina is not inadvertently incorporated into the
stapling device (see Fig. 257B). Palpation of the
vagina is recommended prior to ring the stapler to
reassure the surgeon that the vagina is not involved in
the anastomosis.
Lower Ureteral Injury
Consequence
Unrecognized injury can result in urinary leak and
urinoma. Although uncommon, injury to the lower
ureter usually will occur as the ureter courses more
medially to the trigone and is most vulnerable during
the anterior lateral dissection, especially if there is a
bulky tumor or signicant radiation brosis.
Grade 24 complication
Repair
Injury to the ureter at this level is problematic and
usually warrants a urologic consultation. When the
injury is recognized intraoperatively, the proximal
ureter can be fully mobilized and often reimplanted
into the bladder in a tunneled fashion.40 Primary repair
over a urologic stent is also possible, but stricture may
result, especially in a radiated eld. If the injury is
identied postoperatively, drainage is initially required41
and may necessitate temporary urinary diversion with
a percutaneous nephrostomy tube.42 Occasionally,
the ureteral injury will resolve with proximal urinary
diversion.42 However, if the injury persists, subsequent
operative repairs will include reimplantation using
either a psoas hitch40 or a Boari ap. Another option
involves a ureteroureterostomy43 and, as a last resort,
nephrectomy.
Prevention
As the rectal dissection continues more distally, the
pelvis becomes more narrow. The ureters, which course
into the pelvis quite laterally, begin to veer more medi-
ally to join the trigone. If the dissection of the rectum
is done just along the fascia propria, ureteral injury
should be avoided because the ureter should stay both
lateral and anterior. If the injury is due to tumor size

or pelvic brosis, the dissection is more lateral and the
surgeon should clearly identify the ureter at the pelvic
brim and dissect out the ureter distally for its entire
length. If necessary, the dissection can be done all the
way to the bladder itself. If, after this dissection, it is
determined the distal ureter needs resection to obtain
proper tumor clearance, a controlled resection and
reimplantation can be done. The preoperative place-
ment of ureteral stents can facilitate identication of
the ureter and any intraoperative injuries and should be
considered in difcult cases. The use of intraoperative
indigo carmine can also be employed to identify a sus-
pected intraoperative injury to the distal ureter.
Anterior Resection Syndrome
Consequences
Many patients after a low anterior resection have imper-
fect bowel function. Common complaints include
increased frequency, urgency, fragmentation, inconti-
nence, and constipation.44 Collectively, these symptoms
have been referred to as the anterior resection syndrome.
Unfortunately, these symptoms can be quite debilitat-
ing and can render a technical success a functional
failure. Functional results seem to deteriorate as the
anastomosis is lower in the pelvis.4547 Whereas there
is some improvement with time,48,49 many patients
will have permanent and signicant alterations of
their bowel function.50 Not surprisingly, bowel func-
tion seems worse in patients who have had pelvic
radiation.45,51,52
Grade 1 complication
Repair
No surgical solution exists for the anterior resection
syndrome. Symptoms are probably worse in patients
who have had anastomotic complications, but even
those patients with technically perfect operations can
experience poor bowel function. Because improvement
can occur with time, frustrated patients should be
encouraged to persevere for at least 12 months.48
Symptomatic treatment includes the use of antidiarrhea
agents, a high-ber diet, and the use of barrier creams
to protect the perineal skin. Patients will frequently
need some psychological support and encouragement.53
Whereas many patients have a poor functional outcome,
patient satisfaction is often higher than expected.48,51
This suggests that some patients, despite less than ideal
function, still prefer their situation to the alternative: a
permanent colostomy. Nevertheless, if patients have
continued and life-limiting symptoms, conversion to a
colostomy may be reasonable.
Prevention
There is no way to completely prevent the anterior
resection syndrome. However, because of these sig-
nicant symptoms, alternative techniques have been
developed. These include the use of the colonic J pouch
25 LOW ANTERIOR RESECTION 287
and coloplasty. Most studies suggest improved func-
tion within the rst year, but over time, the functional
outcomes between these alternative techniques and a
straight colorectal anastomosis seem similar. Neverthe-
less, because of the improved immediate result, a
colonic J pouch may be preferred if technically feasible.
A preoperative assessment of anorectal function does
seem warranted prior to performing a very low anasto-
mosis. In patients who have poor anorectal function
prior to surgery, a low anastomosis is likely to provide
poor function and a colostomy may be considered. This
may also be true for patients who have limited access
to bathroom facilities for either personal or professional
reasons. Caution should also be exercised in patients
who are elderly and frail because poor anorectal
function can be extremely debilitating under these cir-
cumstances. Frank discussions about postoperative
function are essential to help patients make informed
decisions.
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resection: a prospective, comparative study. Dis Colon
Rectum 2005;48:20762079.
28. Gastinger I, Marusch F, Steinert R, et al. Protective
defunctioning stoma in low anterior resection for rectal
carcinoma. Br J Surg 2005;92:11371142.
29. Leester B, Asztalos I, Polnyib C. Septic complications
after low anterior rectal resectionis diverting stoma still
justied? Acta Chir Iugosl 2002;49:6771.
30. Cirocco WC, Golub RW. Endoscopic treatment of
postoperative hemorrhage from a stapled colorectal
anastomosis. Am Surg 1995;61:460463.
31. Mayer G, Lingenfelser T, Ell C. The role of endoscopy in
early postoperative haemorrhage. Best Pract Res Clin
Gastroenterol 2004;18:799807.
32. Suchan KL, Muldner A, Manegold BC. Endoscopic
treatment of postoperative colorectal anastomotic stric-
tures. Surg Endosc 2003;17:11101113.
33. Forshaw MJ, Maphosa G, Sankararajah D, et al. Endo-
scopic alternatives in managing anastomotic strictures of
the colon and rectum. Tech Coloproctol 2006;10:
2127.
34. Schlegel RD, Dehni N, Parc R, et al. Results of reopera-
tions in colorectal anastomotic strictures. Dis Colon
Rectum 2001;44:14641468.
35. MacRae HM, McLeod RS. Handsewn vs. stapled anasto-
moses in colon and rectal surgery: a meta-analysis. Dis
Colon Rectum 1998;41:180189.
36. Lucha PA Jr, Fticsar JE, Francis MJ. The strictured
anastomosis: successful treatment by corticosteroid
injectionsreport of three cases and review of the
literature. Dis Colon Rectum 2005;48:862865.
37. Sugarbaker PH. Rectovaginal stula following low circular
stapled anastomosis in women with rectal cancer. J Surg
Oncol 1996;61:155158.
38. Rex JC Jr, Khubchandani IT. Rectovaginal stula:
complication of low anterior resection. Dis Colon Rectum
1992;35:354356.
39. Fleshner PR, Schoetz DR Jr, Roberts PL, et al. Anasto-
motic-vaginal stula after colorectal surgery. Dis Colon
Rectum 1992;35:938943.
40. Ahn M, Loughlin KR. Psoas hitch ureteral reimplantation
in adultsanalysis of a modied technique and timing of
repair. Urology 2001;58:184187.
41. Katz R, Meretyk S, Gimmon Z. Abdominal compartment
syndrome due to delayed identication of a ureteral
perforation following abdomino-perineal resection for
rectal carcinoma. Int J Urol 1997;4:615617.
42. Lask D, Abarbanel J, Luttwak Z, et al. Changing trends in
the management of iatrogenic ureteral injuries. J Urol
1995;154:16931695.
43. Paick JS, Hong SK, Park MS, et al. Management of
postoperatively detected iatrogenic lower ureteral injury:
should ureteroureterostomy really be abandoned? Urology
2006;67:237241.
44. Rasmussen OO, Petersen IK, Christiansen J. Anorectal
function following low anterior resection. Colorectal Dis
2003;5:258261.
45. Bretagnol F, Troubat H, Laurent C, et al. Long-term
functional results after sphincter-saving resection for rectal
cancer. Gastroenterol Clin Biol 2004;28:155159.
46. Nesbakken A, Nygaard K, Lunde OC. Mesorectal excision
for rectal cancer: functional outcome after low anterior
resection and colorectal anastomosis without a reservoir.
Colorectal Dis 2002;4:172176.
47. Lewis WG, Martin IG, Williamson MER, et al. Why do
some patients experience poor functional results after

anterior resection of the rectum for carcinoma? Dis Colon
Rectum 1995;38:259263.
48. Efthimiadis C, Basdanis G, Zatagias A, et al. Manometric
and clinical evaluation of patients after low anterior
resection for rectal cancer. Tech Coloproctol 2004;8(suppl
1):s205s207.
49. Ho YH, Seow-Choen F, Tan M. Colonic J-pouch
function at six months versus straight coloanal anastomosis
at two years: randomized controlled trial. World J Surg
2001;25:876881.
50. Williamson ME, Lewis WG, Finan PJ, et al. Recovery of
physiologic and clinical function after low anterior
25 LOW ANTERIOR RESECTION 289
resection of the rectum for carcinoma: myth or reality? Dis
Colon Rectum 1995;38:411418.
51. Matzel KE, Bittorf B, Gunther K, et al. Rectal resection
with low anastomosis: functional outcome. Colorectal Dis
2003;5:458464.
52. Pollack J, Pahlman L, Gunnarsson U, et al. Late adverse
effects of short-course preoperative radiotherapy in rectal
cancer. Br J Surg 2006;93:15191525.
53. Desnoo L, Faithfull S. A qualitative study of anterior
resection syndrome: the experiences of cancer survivors
who have undergone resection surgery. Eur J Cancer Care
(Engl) 2006;15:244251.
26
Abdominal Perineal Resection
with Colostomy
Charles M. Friel, MD

INTRODUCTION Fecal diversion due to perineal sepsis (e.g., Fourniers

gangrene, Crohns disease, severe perianal hidradenitis,
An abdominal perineal resection (APR) is the complete radiation injury)
removal of the rectum and anus. The most common Disabling incontinence
indication for surgery is adenocarcinoma of the lower Distal benign or malignant stricture
rectum, when performing a primary anastomosis is not Emergency surgery, when an anastomosis is deemed
feasible. When APR is done for cancer, obtaining a not safe
negative circumferential margin is critical, so the dissec-
tion is wide to provide adequate oncologic clearance.
Sometimes, the rectum and anus need to be removed for OPERATIVE STEPS
benign conditions. Under these circumstances, the dissec-
tion can be closer to the rectal wall, which may help Step 1 Abdominal dissection
prevent complications. For the purpose of this discussion, Step 2 Perineal dissection
it is assumed that the indication for surgery is cancer and Incision
the technical points will stress appropriate oncologic tech- Posterior and lateral dissection
nique. These principles are generally applicable to benign Division of anococcygeal ligament
conditions as well. However, on occasion, there are dif- Division of levator ani
ferences in patients with benign disease, and this is noted Anterior dissection
in the text. Closure of perineal wound
Step 3 Creation of end colostomy

INDICATIONS
OPERATIVE PROCEDURE
This is a partial list of surgical indications for an APR
and colostomy. These procedures involve the complete
Abdominal Perineal Resection
removal of the rectum and anus and the creation of an
end colostomy. An APR consists of two separate dissections. When per-
The most common indication is formed by one operating surgeon, the abdominal dissec-
tion is completed rst and then the surgeon will reposition
Very low rectal cancer.
himself or herself and perform the perineal dissection.
Other indications include Because there are two distinct areas of dissection, some
surgeons advocate a synchronous approach, utilizing two
Large polyp not amenable to other techniques (e.g.,
surgeons and a simultaneous abdominal and perineal dis-
endoscopy, transanal, transmission electrom micros-
section.1 Such an approach decreases operative time and
copy [TEM])
can help both surgeons during a difcult case.
Severe pelvic or perineal infection/inammation (e.g.,
radiation injury, pelvic inammatory disease, rectal
perforation, previous anastomotic leak, Crohns Abdominal Dissection
disease)
The abdominal portion of the procedure is similar to a
Other malignancies (e.g., ovarian cancer, retrorectal
very low anterior resection. It is helpful to continue the
tumors, rectal sarcomas, urologic cancer)
abdominal dissection as low as possible, preferably all the
Additional indications for a colostomy include way to the pelvic oor and below the coccyx. As one gets
 292 SECTION III: GASTROINTESTINAL SURGERY
lower in the pelvis, the surgeon needs to be cognizant of
the tumor location and make sure she or he does not cone
in on the rectum, leaving a positive circumferential radial
margin. Otherwise, the abdominal dissection is the same
as for a low anterior resection. Therefore, the complica-
tions and anatomy are also similar. The reader is referred
to Section III, Chapter 25, Low Anterior Resection, for
complications associated with the abdominal portion of
this procedure.
Perineal Dissection
Upon completion of the abdominal dissection, the surgeon
must reposition himself or herself for the perineal dissec-
tion. An elliptical incision is made around the anus,
approximately 2 to 3 cm from the anal verge (Fig. 261).
Once the skin is incised, the dissection is greatly facilitated
by the use of a self-retaining retractor (Fig. 262). The
incision is then carried deeper into the ischiorectal fossa
bilaterally (Fig. 263). No vital structures are located in
the posterior or lateral positions, so dissection in this area
is safe and should be continued more deeply using elec-
Figure 261 Perineum in a patient with rectal cancer. Purple line
demonstrates the location of the incision for malignant disease,
which is outside the external sphincter.
Figure 262 Final appearance after removal of the rectum and
anus. Forceps point to the posterior wall of the prostate.
trocautery. The inferior rectal artery does pass through the
ischiorectal fossa and may result in some minor bleeding.
This artery can usually be controlled with electrocautery
but does occasionally require ligation. As the dissection is
carried posteriorly, there is a tendency for the operating
surgeon to travel too far and get behind the coccyx (Fig.
264). Therefore, careful palpation of the coccyx is critical
to guide the surgeons dissection above the coccyx. Once
the coccyx is clearly identied (Fig. 265), a brous band
extends from the coccyx in the midline position. This is
the anococcygeal ligament and needs to be divided. The
surgeon is now ready to enter the peritoneal cavity just
above the coccyx. This is best done with an assistant
placing a hand behind the rectum all the way to the coccyx
from the abdominal cavity. Then the operating surgeon
should be able to palpate the assistants nger. Mayo scis-
sors are then used to poke through the pelvic oor, just
above the coccyx (Fig. 266). This hole is widened, which
allows the operating surgeon to insert a nger into the
peritoneal cavity and hook the levator ani muscles. Using
electrocautery, these muscles can be divided in both direc-
tions (Fig. 267). Once 75% of this dissection is complete,
Figure 263 Perineum in a patient with Crohns disease. A self-
retaining retractor is in place. Yellow dotted line demonstrates the
location of the incision for an intersphincteric dissection. This dis-
section is appropriate for benign disease.
Figure 264 Abdominal perineal resection (APR), lateral
dissection.
 26 ABDOMINAL PERINEAL RESECTION WITH COLOSTOMY 293

Figure 265 APR, posterior dissection. Figure 267 APR, posterior dissection. The surgeon is about to
use Mayo scissors to poke into the peritoneal cavity just above the
coccyx.

Figure 266 APR, posterior dissection. Forceps point to the

coccyx, which should be palpated.

the top of the rectum can be grasped and pulled through

the perineal defect (Fig. 268). This helps dene the
anterior plane of dissection, which can be the most chal-
lenging. With a hand behind the rectum, the anterior
plane between the rectum and the prostate or the vagina
is developed (Fig. 269). In a man, palpation of the Foley
catheter can help dene this plane (Fig. 2610). In a
woman, a nger in the vagina can be advantageous. The
specimen is nally freed and removed. The perineal wound
is then closed, using several layers of an absorbable suture,
and the skin closed with a subcuticular stitch.

Urethral Injury
Consequence
The anterior portion of the perineal dissection can be
Figure 268 Division of the levator ani muscles.
the most problematic. If the dissection is carried too
far anteriorly in a man, a urethral injury is possible.
Usually, this is immediately evident as the Foley cath- Grade 2/3 complication; grade 4 (if need for pelvic
eter is visualized. Attempts at repair can be made. exenteration)
However, after a repair, a urethral stricture is possible.
If a leak persists, a urethral perineal stula can develop. Repair
If tumor is at the anterior margin, a pelvic exentera- Small defects can be oversewn, using an absorbable
tion with a cystectomy and ileal conduit should be stitch. A frank transaction can be more difcult to treat
performed. and would require an end-to-end anastomosis. If repair
 294 SECTION III: GASTROINTESTINAL SURGERY
Figure 269 Anterior dissection. The rectum pulled through the
perineum.
Figure 2610 Anterior dissection line of the anterior
dissection.
is attempted, prolonged catheterization is warranted.
The catheter should not be removed until radiographic
evidence indicates that a leak has sealed. Unfortunately,
healing can be greatly impaired in an irradiated eld,
which is common if the patient has received neoadju-
vant treatment for a locally advanced rectal cancer.
An intraoperative urologic consultation may be
warranted.
Prevention
Careful palpation of the Foley catheter is important
while performing the anterior dissection. This palpa-
tion will help guide the surgeon to the proper plane
between the prostate and the rectum. Persistent bleed-
ing should alert the surgeon that she or he has ventured
too anteriorly and is getting into the prostate, increas-
ing the likelihood of urethral injury. Between the
rectum and the urethra, there is generally enough pros-
tate to avoid a urethral injury. However, on occasion,
the tumor will extend just adjacent to the capsule of
the prostate or supercially invade the prostate. Under
these circumstances, the dissection can deliberately
extend into the prostate, putting the urethra at greater
risk of injury.2 In these cases, palpation is even more
critical.
If the proctectomy is being done for benign disease, an
intersphincteric dissection may be more appropriate.3 In
this dissection, the intersphincteric groove is identied
and the circular dissection is done between the internal
and the external sphincters (see Fig. 262). The dissection
follows this plane into the peritoneal cavity. With this dis-
section, the levators are not divided. The dissection stays
very close to the rectal wall, decreasing the chances of a
urethral injury.
Vaginal Injury
Consequences
In women, the vagina is just anterior to the rectum.
Therefore, the vagina is susceptible to injury during
the perineal dissection. Because the rectum is being
removed, this rarely results in any long-term sequelae.
In fact, in women with anterior tumors of the
rectum, strong consideration should be given to a pos-
terior vaginectomy to facilitate adequate tumor clear-
ance, which can help to decrease the rate of local
recurrence.
Grade 1 complication
Repair
If an inadvertent injury to the vagina does occur,
primary closure with an absorbable stitch should be
done. However, because the rectum is being removed,
even if this repair were to fail, the posterior wall of the
vagina will often heal by secondary intention without
development of a stula.
Prevention
As in men, careful identication of the anterior plane
is important to prevent inadvertent injury to the vagina.
Persistent bleeding should alert the surgeon that the
well-vascularized vagina is being traumatized and the
plane of dissection should be adjusted more posteriorly.
If the proctectomy is being done for benign disease, an
intersphincteric dissection is appropriate and may
prevent this complication (see the section on Urethral
Injury, earlier).3
Perineal Wound Breakdown
Consequences
Perineal wound breakdown can range from a minor
separation of the skin to a complete disruption of the
wound. This problem is more common in patients who
have had preoperative radiation.4,5 This is particularly
true for patients with a remote history of pelvic radia-
tion who now require surgery.6 For minor disruptions,
healing can be rapid,4 but major wound breakdown can
take months to fully heal.4,5
Grade 1/2 complication (if treated conservatively);
grade 3 complication (if myocutaneous ap required)
 26 ABDOMINAL PERINEAL RESECTION WITH COLOSTOMY 295

Repair
Proper drainage and wound dbridement are necessary
if there is an associated wound infection. Once the
sepsis is controlled, the wound can be packed and
allowed to heal by secondary intention. A vacuum-
assisted closure (VAC) device can also be used, which
may speed up wound healing.7 For a very large defect
that is failing to close, a myocutaneous ap, using either
the gracilis6 or the rectus muscle,8 can be done.9
Prevention
Wound breakdown is often associated with a wound
infection. Therefore, it is important to limit fecal con-
tamination during the perineal dissection. Proper
hemostasis is important to prevent a hematoma that
may get superinfected. Pelvic drains may also help
prevent accumulation of peritoneal uid in the pelvis,
which can leak and cause perineal wound maceration Figure 2611 Circular incision for colostomy at the previously
and subsequent breakdown. marked location.
Whether to perform a primary rectus or gracilis muscle
ap on patients who have been previously radiated contin-
ues to be debated. Proponents of a primary ap note the
relatively high rate of perineal wound complications.8 They
believe wound problems will be lessened if nonirradiated
tissue is used to reconstruct the perineum. Unfortunately,
even with primary ap closures, wound complications can
be encountered.10,11 Therefore, it seems reasonable to save
valuable muscle for reconstruction in those patients who
develop a long-term perineal wound complication. An
exception to this approach may be in patients who have had
a remote history of pelvic radiation. In these patients, the
abnormal perineal tissue is less likely to heal and a primary
ap can be considered.6,8 This scenario is commonly found
in patients with recurrent anal cancer who have been
treated previously with chemoradiation,10 who have a very
high rate of wound failure after primary closure.

Figure 2612 Cruciate incision in the anterior rectus sheath has

Colostomy Creation been done, exposing the rectus abdominus muscle.
Once the perineal dissection is completed, an end colos-
tomy is created. A circular incision is made at a previously
marked location (Fig. 2611). The dissection is carried
through the subcutaneous adipose tissue to the anterior
sheath of the rectus muscle. A cruciate incision is made in
the fascia, and the rectus is identied (Fig. 2612). The
bers of the rectus muscle are then separated and the
posterior sheath exposed. The posterior sheath is also
divided using a cruciate incision (Fig. 2613), and the
defect is dilated to about two ngerbreadths (Fig. 2614).
The colon is then delivered through the abdominal wall
(Fig. 2615) and matured using an absorbable stitch (Fig.
2616).

Stomal Necrosis
Consequences
If supercial, stomal necrosis may result only in some
mucosal sloughing without long-term sequelae. If more Figure 2613 Cruciate incision in the posterior rectus sheath.
 296 SECTION III: GASTROINTESTINAL SURGERY
Figure 2614 Colostomy site is dilated to two ngerbreadths.
Figure 2615 Distal colon is delivered through the colostomy
site without tension.
extensive, the distal portion of the stoma will slough
and lead to a stenotic and recessed stoma. In the worst-
case scenario, the colon will necrose below the level of
the fascia, which can lead to a free intraperitoneal per-
foration and leakage of stool.
Grade 1/2 complication (if supercial); grade 3
complication (if deep)
Repair
Stoma necrosis is a postoperative diagnosis. If the stoma
is just dusky, there may be some minor sloughing
but no further intervention is necessary. When the
mucosa is clearly not viable, the extent of necrosis
should be assessed. This is easily done using a narrow
proctoscope or anoscope. It is necessary to examine
only the distal few centimeters. Usually, there will be
pink mucosa just below the skin. Under these circum-
stances, conservative management is reasonable, recog-
nizing that stenosis may develop in the future. If the
mucosa is not viable below the level of the fascia, an
immediate revision of the colostomy may be necessary.
In patients who will require a permanent stoma, early
revision may be appropriate if revision seems inevitable.
Figure 2616 Final mature colostomy.
In patients with temporary stomas, a conservative
approach is reasonable because the subsequent stenosis
can be addressed at the time of colostomy closure.
Prevention
Stomal necrosis results from poor blood supply to the
distal colon. Proper mobilization of the descending
colon will help decrease the tension on the colon and
prevent this complication. Furthermore, it may be nec-
essary to divide additional mesenteric vessels to also
prevent unnecessary tension. As with an anastomosis,
when colonic mesentery is divided, care must be taken
to protect the marginal artery, which will provide blood
to the distal colon. Finally, the blood supply of the
distal colon can be easily damaged as the surgeon pulls
the colon through the fascial defect, particularly in
obese patients. Therefore, the fascial defect must be
large enough to permit passage of the colon without
undo force. A larger defect will also prevent venous
outow obstruction, which is another cause for isch-
emia and stomal necrosis.
While the surgeon is maturing the stoma, she or he
should pay particular attention to its viability. If, while
closing, the mucosa is clearly ischemic, it may be wise to
revise the stoma prior to leaving the operating room. This
is particularly true in an elective case and if the stoma is
intended to be permanent.
 26 ABDOMINAL PERINEAL RESECTION WITH COLOSTOMY
Figure 2617 Colostomy stenosis.
Other Complications
Stomal Stenosis
Stomal stenosis (Fig. 2617) usually occurs as a result of
stomal necrosis. Once the distal colon sloughs completely,
the stoma will recess and the surrounding skin will begin
to close. Surprisingly, even with a tight stenosis, stool
often passes and some patients can successfully keep a bag
on the opening. As long as the patient is asymptomatic
and a colonoscope can be passed, allowing for surveillance
of the colon, revision may not be necessary. However, if
the patient is symptomatic or if surveillance of the colon
is not possible, a revision of the colostomy should be
done. An attempt can be made via a peristomal incision.
Through this incision, it may be possible to free up some
underlying healthy colon and advance the colon a few
centimeters to redo the colostomy. However, if this is
not possible, a complete revision can be done via an open
or laparoscopic approach. If the stoma is not permanent,
a reversal can be performed when the patient is medically
t.
Parastomal Hernia
By denition, a colostomy creates a defect in the fascia.
This defect must be large enough to pass the colon without
undo force or tension. Furthermore, if the defect is too
small, venous outow may be obstructed and cause stomal
necrosis and subsequent stenosis. However, when the
defect is too large, a parastomal hernia may result. Unfor-
tunately, these hernias are quite common.12 Because of
high failure rates, asymptomatic hernias are often handled
conservatively. If surgical treatment is necessary, two
general approaches are available. Either the surgeon
attempts to tighten or close the fascial defect, leaving
the colostomy in the same location, or the colostomy is
completely resituated.13 The former can be done either via
a peristomal incision or via a transabdominal approach.
Shaping a piece of mesh into a key hole is also com-
monly used, but this is associated with a high recurrence
rate. In general, resituating the stoma is associated
with the lowest recurrence rate.13,14 However, no matter
297
Figure 2618 Colostomy marks in an obese patient. Note
the very high marks (purple circles) necessary under these
circumstances.
the approach, recurrence is common, which may make
the conservative management of an asymptomatic hernia
reasonable.13,14
Leakage
A poorly constructed or poorly placed colostomy can
be extremely morbid. Patients will have a difcult time
keeping a stomal appliance attached, and stool leakage
results. This can lead to signicant skin irritation and is
socially unacceptable. This problem is considerably exac-
erbated if a stoma is placed in a skin crease. For these
reasons, patients should be clearly marked by an experi-
enced enterostomal therapist whenever possible prior to
surgery. This is particularly true in patients who are obese
(Fig. 2618) or in those who have multiple abdominal
scars, when stomal placement can be particularly challeng-
ing. It is also best to have a colostomy protrude approxi-
mately 1 cm above the skin. Flush stomas should be
avoided, because these will often leak and make applying
a stomal appliance difcult. An experienced enterostomal
therapist is critical in marking patients preoperatively and
in assisting with postoperative stomal problems.15
REFERENCES
1. de Canniere L, Rosiere A, Michel LA. Synchronous
abdominoperineal resection without transfusion. Br J Surg
1993;80:11941195.
2. Ike H, Shimada H, Kamimukai N, et al. Extended
abdominoperineal resection with partial prostatectomy for
T3 rectal cancer. Hepatogastroenterology 2003;50:377
379.
3. Lubbers EJ. Healing of the perineal wound after proctec-
tomy for nonmalignant conditions. Dis Colon Rectum
1982;25:351357.
4. Bullard KM, Trudel JL, Baxter NN, et al. Primary perineal
wound closure after preoperative radiotherapy and
 298 SECTION III: GASTROINTESTINAL SURGERY
abdominoperineal resection has a high incidence of wound
failure. Dis Colon Rectum 2005;48:438443.
5. Chadwick MA, Vieten D, Pettitt E, et al. Short course
preoperative radiotherapy is the single most important risk
factor for perineal wound complications after abdomino-
perineal excision of the rectum. Colorectal Dis
2006;8:756761.
6. Shibata D, Hyland W, Busse P, et al. Immediate recon-
struction of the perineal wound with gracilis muscle aps
following abdominoperineal resection and intraoperative
radiation therapy for recurrent carcinoma of the rectum.
Ann Surg Oncol 1999;6:3337.
7. Greer SE, Duthie E, Cartolano B, et al. Techniques for
applying subatmospheric pressure dressing to wounds in
difcult regions of anatomy. J Wound Ostomy Conti-
nence Nurs 1999;26:250253.
8. Chessin DB, Hartley J, Cohen AM, et al. Rectus ap
reconstruction decreases perineal wound complications
after pelvic chemoradiation and surgery: a cohort study.
Ann Surg Oncol 2005;12:104110.
9. Anthony JP, Mathes SJ. The recalcitrant perineal wound
after rectal extirpation. Applications of muscle ap closure.
Arch Surg 1990;125:13711376; discussion 13761377.
10. Christian CK, Kwaan MR, Betensky RA, et al. Risk factors
for perineal wound complications following abdominoperi-
neal resection. Dis Colon Rectum 2005;48:4348.
11. Kapoor V, Cole J, Frank I, et al. Does the use of a ap
during abdominoperineal resection decrease pelvic wound
morbidity? Am Surg 2005;71:117122.
12. Arumugam PJ, Bevan L, Macdonald L, et al. A prospective
audit of stomasanalysis of risk factors and complications
and their management. Colorectal Dis 2003;5:4952.
13. Rieger N, Moore J, Hewett P, et al. Parastomal hernia
repair. Colorectal Dis 2004;6:203205.
14. Rubin MS, Schoetz DJ Jr, Matthews JB. Parastomal
hernia. Is stoma relocation superior to fascial repair? Arch
Surg 1994;129:413418; discussion 418419.
15. Park JJ, Del Pino A, Orsay CP, et al. Stoma complica-
tions: the Cook County Hospital experience. Dis Colon
Rectum 1999;42:15751580.
27
Laparoscopic Appendectomy
C. Joe Northup, MD
INTRODUCTION
Laparoscopic appendectomy (LA) is rapidly becoming the
standard of care for surgical removal of the appendix.
Acute appendicitis is a diagnostic possibility in nearly every
patient who presents emergently with abdominal pain.
Despite the recent improvements in diagnostic imaging,
appendicitis is often confused with other inammatory
processes, and it presents a challenging clinical diagno-
sis. Ovarian torsion/abscess, diverticulitis, inammatory
bowel disease, and other conditions can all present with
symptoms similar to those of acute appendicitis.1
A thorough history and physical examination continue
to be the most efcient methods of clinical diagnosis.
Generalized abdominal pain migrating to the right lower
quadrant (RLQ) with associated leukocytosis is the classic
presentation for acute appendicitis. Frequently, however,
the source of abdominal pain is less certain, especially in
the female patient. Diagnostic studies such as computed
tomography (CT) scan and ultrasound have been shown
to be benecial when the diagnosis is not clear.2,3 Yet no
imaging study has been able to replace careful evaluation
of the patients symptoms and physical examination
ndings.4
Indications for LA remain the same as those for
open appendectomy (OA), with acute appendicitis being
the most common reason for appendectomy. Chro-
nic appendicitis is a more controversial diagnosis, most
commonly associated with patients in the pediatric pop-
ulation. Recurrent RLQ pain, which does not go on to
develop into severe pain or localized peritonitis, is the
most frequent complaint associated with chronic appen-
dicitis. Some surgeons advocate elective appendectomy
in this group and have demonstrated relief of symptoms
in many patients.5 Perforated appendicitis with subse-
quent abscess formation can be safely managed with
percutaneous drainage and interval appendectomy once
the acute inammation has resolved. Tumors of the
appendix can demonstrate a wide variety of pathology.
The presence of a lesion in the appendix is an indica-
tion for appendectomy, and the differential diagnosis
includes appendiceal cysts, adenocarcinoma, and carci-
noid tumors.
The addition of the laparoscopic approach over tradi-
tional appendectomy has yielded many benets. Improved
visualization of the abdominal cavity obtained with lapa-
roscopy is particularly benecial when the diagnosis of
acute appendicitis is uncertain. LA has been found to have
a decreased length of stay, a lower readmission rate, and
a decrease in overall complications.6 In recent articles,
there has not been a signicant increase in cost between
LA and OA. As with many laparoscopic procedures, LA
has been demonstrated to have a decrease in narcotic use
and an earlier return to work than OA.7
Complications from LA may be increased in patients
who are elderly or morbidly obese or in those with
perforated appendicitis.8 Also, the previously operated
abdomen can add further challenge to any laparoscopic
procedure. Consideration must be given to peritoneal
access and port placement depending on previous surgical
history. The overall complication rates of LA range
from 6% to 13% with a very low risk of mortality.9,10
Careful identication of structures and careful dissection
will help avoid many intraoperative and postoperative
complications.
INDICATIONS
Acute appendicitis
Chronic appendicitis
Interval appendectomy
Neoplasm
OPERATIVE STEPS
Step 1 Patient positioning and trocar insertion
Step 2 Mobilization of appendix/cecum
Step 3 Dissection of appendix and mesoappendix
Step 4 Division of mesentery
Step 5 Resection of appendix
Step 6 Specimen removal
Step 7 Trocar removal
 300 SECTION III: GASTROINTESTINAL SURGERY
OPERATIVE PROCEDURE
Trocar Insertion
Trocar Insertion Injuries
For general injuries related to trocar placement, refer to
Section I, Chapter 7, Laparoscopic Surgery.
Bladder Injury
Consequence
Intra-abdominal contamination. Early diagnosis of this
injury is critical. Patients with missed injuries will often
present to the emergency department with complaints
of atypical abdominal pain, frequently associated with
large amounts of drainage from the wound. Associated
hematuria is also common. Imaging studies are very
helpful in diagnosing this complication because a CT
scan will typically demonstrate a large amount of non-
loculated peritoneal uid. Contrast extravasation may
be present in the pelvis on a standard CT scan, and a
CT cystogram is the most accurate method for conr-
matory diagnosis of this injury. Delayed presentation
of this complication can present with oliguria and acute
renal failure. Patients can also go on to develop perito-
nitis and, eventually, sepsis.
Grade 2/3 complication
Repair
Bladder injuries are repaired with a two-layer, primary
closure and can be completed laparoscopically. If there
is a question of injury during the procedure, retrograde
lling of the bladder may be helpful in demonstrating
the injury. The distended bladder will also allow for an
easier repair of the injury. A urinary catheter should be
left in place for 10 to 14 days after the repair to allow
for adequate healing.11 Prior to removal of the urinary
catheter, a formal cystogram should be performed to
conrm that the repair has healed satisfactorily.
Prevention
Trocar insertion in the pelvis, and in all areas of the
abdomen, should be done under direct vision (Fig.
271). A distended bladder can often reach as high as
the umbilicus in some patients, and a urinary catheter
should be placed prior to the start of any laparoscopic
pelvic surgery. Injury to the bladder with instrumenta-
tion is uncommon during LA; however, care should
always be taken when dissecting an inamed appendix
from the peritoneum.
Epigastric Vessel Injury
Consequence
Severe bleeding. Before trocars are placed along the
midclavicular line, thought must be given to the loca-
tion of the epigastric vessels. Injuries to these vessels are
often missed at the time of surgery owing to compres-
sion by the trocar and the presence of a pneumoperi-
toneum. Frequently, signicant hemorrhage does not
Figure 271 Trocar insertion. The operating port in the left
lower quadrant is placed under direct vision to avoid injury to the
sigmoid colon (C) or other structures.The trocar should be inserted
just lateral to the epigastric vessels (E).
occur until the trocar is removed and the pneumoperi-
toneum is released. Considerable bleeding can result
from this injury, requiring transfusion, reoperation, or
the development of a large rectus sheath hematoma.
Grade 2 complication
Repair
Once the vessel has been injured, it typically requires
ligation to control bleeding. Using a port closure device
and absorbable suture is typically the most efcient
method to manage this complication. Two to three
sutures placed perpendicular to the path of the vessel
are usually required to adequately ligate the vessel. If
unsuccessful, increasing the incision of the port site is
required to directly suture the vessels. Once the bleed-
ing is under control, the abdominal pressure should be
decreased to allow for identication of further hemor-
rhage that may be controlled by the presence of the
distended abdomen.
Prevention
Visualization of the epigastric vessels should be
attempted before placing the trocar in the vicinity of
the vessels. Also, an estimation of the border of the
rectus muscle should be made. Trocars for this proce-
dure should be placed just lateral to the rectus edge in
the left lower quadrant.
Wound Infection
Consequence
Severe complications. The overall wound infection for
LA remains quite low. However, supercial skin infec-
tions can increase the rate of incisional hernia and result
in increased pain and delayed recovery. Rarely, a super-
cial skin infection can progress to more aggressive
infection or necrotizing fasciitis.
Grade 1/2 complication
 27 LAPAROSCOPIC APPENDECTOMY 301

Figure 272 Removal of the specimen. The appendix has been Figure 273 Identication of the appendix. The appendix can
placed into a specimen pouch and is being removed from the often be difcult to identify when inamed. Identication of the
abdomen. This prevents the contaminated appendix from coming superior taenia coli (T) and following it toward the cecum (C) will
into direct contact with the subcutaneous tissue. lead to the base of the appendix (A).

Repair
The vast majority of supercial infections can be
managed with simple wound management. Allowing
the wound to heal by secondary intention with daily
dressing changes is often the only intervention neces-
sary. Cultures should be taken when the wound is
opened and antibiotics reserved for patients with asso-
ciated cellulitis.
Prevention
Most studies demonstrate that preoperative antibiotics
are indicated prior to an appendectomy to decrease the
rate of wound infection.12 In the presence of a perfo-
rated appendix or severe contamination, primary wound
closure may not be indicated. Perforated appendicitis
increases the wound infection rate to 15%.13 If the
intra-abdominal ndings increase the concern of a Figure 274 Attachments to the appendix. The appendix is often
wound infection, the skin incision can be left open to located in a retrocolic position, or it will have brous attachments
allow drainage of any subcutaneous wound infections. to the retroperitoneum.
Wound contamination may also occur during removal
of the specimen. Placing the resected appendix into a
specimen pouch is advocated to decrease wound expo-
sure to the contaminated tissue (Fig. 272).
Dissection of the Appendix and
the Mesoappendix
Injury to the Colon
Consequence
Intra-abdominal contamination with development of
peritonitis or abscess. Careful dissection must be per-
formed when mobilizing the appendix, especially in the
presence of periappendiceal inammation (Figs. 273
to 275). During laparoscopic procedures, the expected
incidence of intestinal injury is less than 1%.14 Delayed
presentation of a colonic injury can have severe conse- Figure 275 Mobilization of the appendix (A) and cecum (C). The
quences. A patient with an unrecognized colonic injury attachments to the appendix are being taken down sharply. Thermal
typically presents with abdominal pain and fever. If the energy is avoided to decrease the risk of injury to the colon.
 302 SECTION III: GASTROINTESTINAL SURGERY
Figure 276 Dissection of appendix. In this gure, a space is
being developed between the appendix and its mesentery. The
relationship of the appendix to the cecum must be maintained to
avoid cecal injury.
injury was small, the patient may have a simple abscess
that can be treated with intravenous antibiotics and
percutaneous drainage. The patient can also arrive with
peritonitis and develop sepsis or further complications.
Grade 3/4 complication
Repair
Nearly all enterotomies can be closed primarily, even
without mechanical bowel preparation. An identied
injury should be carefully inspected for evidence of
devitalized tissue or potential narrowing after repair.
Also, routine inspection of the cecum and the appen-
diceal stump should be done upon removal of the
appendix to search for possible bowel injury, because
this is a much more devastating problem if missed. If
the surgeon has a high degree of suspicion of an injury
that cannot be clearly identied laparoscopically, she or
he should not hesitate to convert to an open procedure.
An enterotomy can easily be repaired laparscopically if
the surgeon is familiar with intracorporeal suturing
techniques. Otherwise, an RLQ or lower midline inci-
sion will be required to repair the colon injury. Primary
repair with a two-layer closure is typically adequate.
Drain placement can be avoided unless peritoneal con-
tamination is signicant.
Prevention
The operating surgeon should always maintain careful
dissection when mobilizing the cecum and appendix.
The relationship of the appendix and cecum should be
determined to help identify the angle to approach the
space posterior to the appendix. This is especially
important when creating a space between the appendix
and its mesentery (Fig. 276). The tip of the instru-
ment should be clearly visualized while developing this
plane (Fig. 277). Also, minimal use of cautery is advo-
cated during dissection to avoid indirect thermal injury
to the intestine.
Figure 277 Completion of the dissection. An instrument has
been passed between the appendix and the mesoappendix. Ade-
quate space has been developed to allow passage of a stapling
device.
Ureteral Injury
Consequence
Contamination of the abdominal cavity. Iatrogenic ure-
teral injury is an uncommon yet signicant injury
during LA. These injuries are often not identied at the
time of surgery and are diagnosed postoperatively.
Delayed presentation of this injury will often bring the
patient into the emergency department with abdominal
pain, leukocytosis, and fever. A CT scan will demon-
strate free uid in the abdomen with or without hydro-
nephrosis. If the injury results in occlusion of the ureter,
a delay in diagnosis may result in renal parenchymal
damage.
Grade 2/3 complication
Repair
The type of injury dictates the method of repair. Imme-
diate identication of the injury with prompt primary
repair results in the best long-term outcome. A mono-
lament suture should be used to close the defect or
perform an ureteroureterostomy in the case of com-
plete transection. With late presentation, the injured
ureter may not be viable and requires resection to
healthy tissue. Primary repair is used for an injury in
the proximal two thirds and bladder reimplantation for
injuries in the distal one third. In the case of signicant
loss of length, anastomosis to the contralateral ureter
may be necessary. Stenting of the injured area will assist
in decreasing the rate of postoperative stricture.
Prevention
The ureter is most at risk during the dissection of the
appendix and cecum. This risk is increased with a ret-
rocecal appendix or in the presence of severe inamma-
tion. The operating surgeon should be aware of the
possible location of the ureter during the mobilization
of the cecum (see Fig. 275). Maintaining careful dis-
 27 LAPAROSCOPIC APPENDECTOMY 303

section within the avascular plane will allow for careful

identication of structures and avoidance of this injury.

Division of the Mesentery

Mesenteric Bleeding
Consequence
Postoperative bleeding requiring reoperation or devel-
opment of infected hematoma. Tearing of the mesoap-
pendix can result in bleeding from the appendiceal
artery or its branches. Whereas this can appear to be a
signicant problem initially, clinically signicant post-
operative hematomas occur in less than 1% of patients
after LA.15 Despite these data, careful hemostasis should
always be maintained.
Grade 13 complication
Figure 278 Division of the mesoappendix. A stapler has been
Repair placed completely around the mesoappendix. The tip of the stapler
The majority of intraoperative bleeding from the mes- should be visualized beyond the mesentery to ensure complete
entery will be controlled with direct pressure using a division.
blunt grasper. When approaching hemorrhage in this
area, rst start with a clear operative eld. Irrigate the
area to help precisely identify the area of the mesoap-
pendix that is bleeding. If the mesentery remains of
adequate length, an endoloop may be placed around
the entire mesoappendix. Otherwise, cautery can be
used to coagulate small bleeders from the staple line.
The surgeon must be careful to identify the proximity
of the terminal ileum and the cecum before trying to
control bleeding using thermal energy. Suture ligation
may be performed to control hemorrhage if the previ-
ous steps fail.
Prevention
No study has demonstrated a comparative advantage
regarding division of the mesoappendix. The primary
step to prevent bleeding from the mesentery is to
conrm that the stapler, endoloop, and other instru- Figure 279 Division of the appendix. When placing the stapler
ments are completely around the mesoappendix (Figs. on the appendix, the tips must be visualized as well as conrming
278 and 279). When using a stapling device, the the cecum is not entrapped by the device.
surgeon should make sure to use a staple load appropri-
ate for the thickness of the tissue. The staple lines of
both the mesentery and the appendix should be evalu-
ated for bleeding or intestinal injury (Fig. 2710).

Resection of the Appendix

Appendiceal Stump Leak
Consequence
Tearing of the appendix at its base or avulsion of the
appendix from the cecum. In the presence of a perfo-
rated appendix or severe inammation, the appendix
can become extremely friable. Upon delayed presenta-
tion, the appendix may perforate near its base and not
allow adequate space to safely secure the base. This
complication can lead to intra-abdominal contamina-
tion, increasing the risk of a postoperative abscess or Figure 2710 Evaluation of the staple lines. The staple lines
wound complication. should always be inspected to conrm that there is no bleeding and
Grade 2 complication no injury to the surrounding tissue.
 304 SECTION III: GASTROINTESTINAL SURGERY
Figure 2711 Difcult appendiceal stump. Here the appendiceal
stump is completely involved with carcinoid tumor.
Figure 2712 Partial cecectomy. The laparoscopic stapler has
been placed below the lesion (T) and across the end of the cecum.
The insertion of the terminal ileum (TI) into the right colon (RC)
must be carefully identied.
Repair
Management of the complicated appendiceal stump
varies depending on the severity of the injury. Several
techniques can be used to control the appendix base.16
If the base is easily visualized, a laparoscopic stapler can
be used to perform a partial cecectomy with resection
of the appendiceal stump. A similar technique can be
used in the presence of a tumor in the appendix (Fig.
2711). Again, the relationship to the terminal ileum
must be identied so as not to inadvertently injure or
narrow the intestinal lumen (Fig. 2712).
Prevention
Often, the difcult appendiceal stump is due to perfo-
ration or severe inammation of the appendix and
unavoidable. During the mobilization of the appendix,
the surgeon must be careful not to place too much
tension on the appendix. The tissue can be extremely
friable in advanced or perforated appendicitis and can
easily tear, leaving inadequate tissue for ligation of the
stump.
Stump Appendicitis
Consequence
Abscess or abdominal contamination. Stump appendi-
citis is an uncommon complication after appendec-
tomy.17 The greatest obstacle in dealing with this
problem is the diagnostic challenge it creates. RLQ
pain in a patient with a previous appendectomy can
create confusion for the evaluating physician and com-
monly results in a delay in treatment. Owing to the
previous resection, diagnostic imaging is not benecial.
The most common presentation will appear very late in
the course of appendicitis, with the diagnosis delayed
until the patient develops an abscess or peritonitis.18
Grade 2 complication
Repair
Management of stump appendicitis can be performed
by partial cecectomy. However, if the patient has a
delayed presentation, the resultant inammation and
contamination may require an ileocecectomy.
Prevention
The resection of the appendix should leave a stump
approximately 1 cm in length. A stump longer than this
will be at risk for recurrent appendicitis.
Postoperative Abscess
Consequence
Abdominal pain, fever, and possibly, sepsis. This com-
plication occurs in approximately 8% to 25% of patients
after appendectomy and is increased in the presence of
perforation.19 These patients will most often present to
the emergency department with pain, fever, and leuko-
cytosis between 3 and 7 days after an appendectomy.
If not treated promptly, the abscess can develop into a
stula or generalized sepsis.
Grade 2 complication
Repair
CT- or ultrasound-guided drainage and antibiotics will
resolve the abscess in the majority of patients with this
complication. If percutaneous drainage fails, the patient
can be explored laparoscopically for drainage of the
abscess. In this situation, the surgeon should carefully
evaluate the cecum and terminal ileum for a possible
missed bowel injury or stump leak. A high index of
suspicion and early CT scan in patients who have an
atypical postoperative course will allow for prompt
identication and treatment of an intraperitoneal
abscess.
Prevention
Avoidance of intra-abdominal contamination is the
primary method of postoperative abscess prevention.

Controversy exists whether preoperative antibiotics,
or prolonged intravenous antibiotics in the case of
perforation, will decrease the incidence of abscess
formation.
REFERENCES
1. Lally KP, Cox CS Jr, Andrassy RJ. The appendix. In
Townsend CM Jr, Beauchamp RD, Evers BM, Mattu KL
(eds): Sabiston Textbook of Surgery, 16th ed. Philadel-
phia: WB Saunders, 2001; p 920.
2. Zielke A, Hasse C, Sitter H, Rothmund M. Inuence of
ultrasound on clinical decision making in acute appendici-
tis: a prospective study. Eur J Surg 1998;164:201209.
3. Raman SS, Lu DS, Kadell BM, et al. Accuracy of nonfo-
cused helical CT for the diagnosis of acute appendicitis:
a 5-year review. AJR Am J Roentgenol 2002;178:1319
1325.
4. Lee SL, Walsh AJ, Ho HS. Computed tomography and
ultrasonography do not improve and may delay the
diagnosis and treatment of acute appendicitis. Arch Surg
2001;136:556562.
5. Onders RP, Mittendorf EA. Utility of laparoscopy in
chronic abdominal pain. Surgery 2003;134:549552.
6. Nguyen NT, Zainabadi KM, Mavandadi SA, et al. Trends
in utilization and outcomes of laparoscopic versus open
appendectomy. Am J Surg 2004;188:813820.
7. Ortega AE, Hunter JG, Peters JH, et al. A prospective,
randomized comparison of laparoscopic appendectomy
with open appendectomy. Am J Surg 1995;189:208212.
8. Carbonell AM, Burns JM, Lincourt AE, Harold KL.
Outcomes of laparoscopic versus open appendectomy. Am
Surg 2004;70:759765.
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9. Ball CG, Kortbeek JB, Kirkpatrick AW, Mitchell P.
Laparoscopic appendectomy for complicated appendicitis:
an evaluation of postoperative factors. Surg Endosc 2004;
18:969973.
10. Schirmer BD, Schmieg RE Jr, Dix J, et al. Laparoscopic
versus traditional appendectomy for suspected appendici-
tis. Am J Surg 1993;165:670675.
11. Armenakas NA, Pareek G, Fracchia JA. Iatrogenic bladder
perforations: long-term follow-up. J Am Coll Surg 2004;
198:7882.
12. Busuttil RW, Davidson RK, Fine M, Topkins RK. Effect
of prophylactic antibiotics in acute nonperforated appendi-
citis: a prospective, randomized, double-blind clinical
study. Ann Surg 1981;194:502509.
13. Lin HF, Wu JM, Tseng LM, et al. Laparoscopic versus
open appendectomy for perforated appendicitis. J Gastro-
intest Surg 2006;10:906910.
14. Thomson SR, Fraser M, Stupp C, Baker LW. Iatrogenic
and accidental colon injurieswhat to do? Dis Colon
Rectum 1994;37:496502.
15. Vo N, Hall FM. Severe post appendectomy bleeding. Am
Surg 1983;49:560562.
16. Poole GV. Management of the difcult appendiceal
stump: how I do it. Am Surg 1993;59:624625.
17. Liang MK, Lo HG, Marks JL. Stump appendicitis: a
comprehensive review of the literature. Am Surg 2006;72:
162166.
18. van den Broek WT, Bijnen AB, de Ruiter P, Gouma DJ.
A normal appendix found during diagnostic laparoscopy
should not be removed. Br J Surg 2001;88:251
254.
19. Piskun G, Kozik D, Rajpal S, et al. Comparison of
laparoscopic, open, and converted appendectomy for
perforated appendicitis. Surg Endosc 2001;15:660662.
28
Hemorrhoidectomy
Eugene F. Foley, MD
INTRODUCTION
Although many nonresective procedures have been
described for the treatment of hemorrhoidal disease over
the years, surgical hemorrhoidectomy continues to main-
tain an important role in the therapy of hemorrhoids and
may be one of the most common anorectal operations
performed by the general surgeon. Because surgical hem-
orrhoidectomy has been done for many decades, ample
evidence indicates that this procedure can be done safely,
with a low complication rate and with a high degree of
effectiveness in the reduction of hemorrhoidal symp-
toms.1 Despite this efcacy, surgical hemorrhoidectomy
has well-described, specic complications, and their
existence and the steps in their prevention should be
well understood by the surgeon embarking upon these
cases.
In addition, the substantial postoperative pain associ-
ated with surgical hemorrhoidectomy is well recognized.2
In an attempt to reduce this morbidity, a new technique,
stapled hemorrhoidectomy (also referred to as procedure for
prolapse and hemorrhoids [PPH]), has been introduced.
This chapter describes both the traditional closed Fer-
guson excisional hemorrhoidectomy3 and the stapled
hemorrhoidectomy, with emphasis on the operative steps
and the avoidance of the specic technical complications
associated with each.
Traditional
Hemorrhoidectomy
INDICATIONS
Hemorrhoidal symptoms not amenable to conservative
bowel manipulation
Internal hemorrhoids larger than grade 2, not amen-
able to ofce procedures such as banding
Symptomatic hemorrhoids with a large external
component
OPERATIVE STEPS
Step 1 Prone positioning/anesthetic considerations
Step 2 Anoscopy and operative planning
Step 3 Ligation of the pedicle
Step 4 Excision of the hemorrhoidal complex
Step 5 Religation of the pedicle and incision closure
Step 6 Attention to other quadrants
Step 7 Application of local anesthesia
OPERATIVE PROCEDURE
Anesthetic Considerations
Urinary Retention
Urinary retention, due to overdistention of the bladder
during surgery or postoperative levator spasm from inci-
sional pain, is one of the most common complications of
anorectal surgery, including hemorrhoidectomy. Large
series have reported this complication as frequently as 25%
to 35%.4
Consequence
Urinary retention after anorectal surgery can substan-
tially increase the morbidity of hemorrhoidectomy by
delaying the discharge of patients after this day-surgery
procedure or by requiring emergent reevaluation of the
patient later in the day. The need for urinary drainage
may also increase the potential for urinary tract
infection.
Grade 1/2 complication
Repair
Urinary retention after hemorrhoidectomy is treated
by temporary urinary drainage with a Foley catheter,
typically over a 48-hour period. The need for formal
urologic evaluation is rare, except in patients with sub-
stantial urologic difculties that were present preopera-
tively. Conservative measures, including voiding while
submerged in a tub of warm water, may avoid the need
for catheterization.
Prevention
Steps taken to avoid acute overdistention of the bladder,
including the use of a heparin lock rather than con-
 308 SECTION III: GASTROINTESTINAL SURGERY

tinuous intravenous uid administration and preopera-

tive voiding, have been shown to decrease the incidence
of urinary retention after hemorrhoidectomy.57 Ade-
quate administration of local anesthetics (bupivacaine
[Marcaine]) may also reduce early postoperative levator
spasm, leading to less urinary retention after surgery.

Anoscopy and Operative Planning

Inappropriate Hemorrhoidal Excision
Prior to excision, a full operative plan needs to be
established by careful anoscopy. Typically, either two or
three hemorrhoidal complexes are excised. Even most
circumferential hemorrhoids can be grouped for exci-
sion into the common hemorrhoidal quadrants: left lateral,
right posterior, and right anterior.
Figure 281 Ligation of the hemorrhoidal pedicle, including the
Consequences mucosa, submucosa, and hemorrhoidal plexus.
Failure to fully plan the excisions at the start of the
operation will lead either to inadequate excision and
persistent symptoms or to overaggressive resection and
subsequent anal stenosis.
Grade 1/2/3 complication
Repair
If an inadequate resection is initially made, additional
resection can be done at the end of the case. Anal ste-
nosis and its treatment are discussed later.
Prevention
Careful preexcision planning is mandatory to obtain an
adequate and appropriate hemorrhoid resection.

Ligation of the Pedicle

Hemorrhage
Consequences
Failure to adequately ligate the plexus can result in
signicant postoperative bleeding from the pedicle,
which can require reoperation to control. The rate
of this complication should be less than 1%,8 but it
represents one of the most serious complications of
hemorrhoidectomy.
Grade 2/3 complication
Repair
Pedicle bleeding recognized at the time of initial surgery
can be simply religated. Identication and resuturing
of the pedicle may be facilitated by leaving the pedicle
suture long and in place while the excision and inci-
sional closure are completed. Once the excisions are all
completed and the incisions closed, the pedicles can all
be examined carefully for persistent bleeding. Signi-
cant hemorrhage in the early postoperative period
requires reexploration and ligation.
Prevention
Deeply ligating the pedicle well within the rectal vault,
including the mucosa and submucosa and encircling
Figure 282 The pedicle suture secured well within the rectal
vault, high above the dentate line.
the entire hemorrhoidal plexus, will minimize the inci-
dence of postoperative bleeding (Fig. 281).
Anal Stenosis
Placing the pedicle sutures too low, within the narrow anal
canal rather than the capacious distal rectum, may lead to
an increase in the likelihood of postoperative anal stenosis
(Fig. 282). The consequences and repair of this compli-
cation are discussed later.
Excision of the Hemorrhoidal Pedicle
Sphincter Injury
Once ligated in the distal rectum, the hemorrhoidal plexus
and its overlying epithelium are sharply excised starting
peripherally on the perianal skin. A plane is developed
between the hemorrhoid and the underlying sphincter
complex, which should be easily identied (Fig. 283).

Figure 283 The sphincter complex underlying the hemorrhoidal
plexus.
Consequence
Inadequate visualization of the underlying sphincter
complex can lead to sphincter injury and weakening.
The incidence of this complication should be extremely
low, less than 0.5%.9
Grade 2/3 complication
Repair
Although quite unusual, future sphincteroplasty to
repair sphincter injury after surgical hemorrhoidectomy
may be indicated.9
Prevention
Careful identication and preservation of the sphincter
beneath the hemorrhoid should essentially elimin-
ate the chance of signicant sphincter injury during
hemorrhoidectomy.
Anal Stenosis
Anal stenosis remains one of the most serious complica-
tions of hemorrhoidectomy. Poor planning or execution
of a number of steps during the hemorrhoidectomy
including poor exposure, inadequate anesthesia, low
ligation of the pedicles, and excessive excisionmay
contribute to this complication.
Consequence
The excision of excessive anal canal mucosa during the
hemorrhoid excision is the most common factor leading
to anal stenosis. This serious complication of hemor-
rhoidectomy occurs with a frequency of 2% to 4%.10 It
is potentially a source of symptomatic distal gastroin-
testinal obstruction, which may carry substantial mor-
bidity and, in its more severe forms, may require
surgical correction.
Grade 2/3 complication
28 HEMORRHOIDECTOMY 309
Figure 284 A narrow epithelial excision, reducing the likelihood
of postoperative anal stenosis.
Repair
Persistent symptomatic anal stenosis after hemorrhoid-
ectomy is an indication for anoplasty, often requiring
the use of local skin aps to reconstruct and reepithe-
lialize the resected anal canal mucosa. This procedure
is typically done at a second stage.11,12
Primary repair when this complication is recognized at
the initial operation could be accomplished by conversion
to a Whitehead hemorrhoidectomy. When done correctly,
this involves primary mobilization of the perianal skin
circumferentially, reepithelializing the distal anal canal
with perianal skin advanced to the native dentate line.
Prevention
Prevention of anal stenosis requires substantial vigi-
lance in maintaining adequate anal canal epithelium
during excision. General or spinal anesthesia is critical
to allow adequate visualization during the dissection,
and prone positioning also facilitates the exposure. The
extent of epithelial resection should be small, leaving
narrow incisions that can be closed without stricture
(Fig. 284). This is especially true with larger hemor-
rhoids or during emergency surgery for incarcerated
hemorrhoids. Larger hemorrhoids can be excised by
raising anal mucosal aps bilaterally and removing addi-
tional hemorrhoidal tissue while preserving overlying
mucosa. Care should also be made to preserve some
anal canal mucosa between resection lines. The place-
ment of a large Hill-Ferguson anal retractor during the
resection, and the ability to place this retractor at the
end of the procedure, usually indicates that the anal
canal will not be stenotic (Fig. 285).
Inadequate Hemorrhoidal Excision
Consequences
Inadequate excision of the hemorrhoidal plexus will
lead to persistent symptoms of hemorrhoidal disease,
 310 SECTION III: GASTROINTESTINAL SURGERY

Religation of the Pedicle and Incisional Closure

Postoperative Hemorrhage
Religation of the pedicle is another important step in
reducing the incidence of postoperative bleeding, as dis-
cussed earlier.

Whitehead Deformity
Figure 285 A large Hill-Ferguson anal retractor in the anal canal
at completion of the surgery, indicating adequate preservation of
the anoderm.
Consequence
During the incisional closure, care is taken to align
the incision edges, re-creating the dentate line, and
realigning rectal mucosa, anal mucosa, and perianal
skin. Failure to do so may result in a Whitehead
deformity, which is created by malalignment of these
layers, suturing rectal mucosa to the perianal skin,
resulting in chronic anal drainage from externalized
mucosa.14
Grade 1/2 complication
Repair
The formation of a symptomatic Whitehead deformity
requires a second operation for repair in the form of an
anoplasty to re-create the dentate line and internalize
all mucosa.14
Prevention
Care taken in full religation of the pedicle and judicious
realignment of the mucosal levels will reduce the likeli-
hood of these complications.

Stapled
Hemorrhoidectomy
Figure 286 A completed hemorrhoidectomy, with incisions (Procedure for Prolapse
extending well out onto the perianal skin, fully resecting all external
tags and preventing a dog ear at the external end of the incision. and Hemorrhoids)
including prolapsing tissue, bleeding, and excessive INDICATIONS
perianal skin tags. A properly done hemorrhoidectomy
should lead to an acceptable resolution of hemorrhoidal Symptomatic hemorrhoids refractory to conservative
symptoms in 90% of patients.13 therapy, with a predominance of internal component
Grade 1/2 complication
Repair
Persistent symptoms after hemorrhoidectomy may
require additional hemorrhoid surgery, an incidence
OPERATIVE STEPS
that should be less than 5% to 10%.13
Step 1 Anesthetic considerations and positioning
Prevention Step 2 Placement of operating anoscope and
Adequate excision of the hemorrhoids needs to be obturator
evaluated at the time of the initial surgery. Persistent Step 3 Pursestring placement
perianal skin tags may be prevented by starting the Step 4 Introduction of stapling device and securing of
excision out at the periphery on the perianal skin, fully pursestring
excising the entire external component, and reducing Step 5 Closure and ring of stapling device
the possibility of a persistent perianal skin dog ear (Fig. Step 6 Removal and inspection of staple line and excised
286). tissue

Figure 287 The pursestring suture being placed during a pro-
cedure for prolapse and hemorrhoids (PPH).
OPERATIVE PROCEDURE
Anesthetic and Positioning Considerations
Prone positioning, general or spinal anesthesia, and
judicious uid management are highly recommended for
stapled hemorrhoidectomy, for the same reasons outlined
for excisional hemorrhoidectomy.
Placement of the Anoscope, Obturator,
and Pursestring Suture
The operating anoscope and obturator are placed well into
the distal rectum to allow an adequately high placement
of the pursestring suture. A 2-0 Prolene pursestring suture
is then placed at a level well within the rectal vault and
deep enough to include the mucosal and submucosal
layers. Care is taken to leave only small gaps between the
bites and to try to keep the pursestring at a uniform dis-
tance from the dentate line circumferentially (Figs. 287
and 288).
Inadequate Excision
Consequence
Large gaps between the pursestring bites or uneven
levels of the pursestring in relation to the dentate line
will increase the chances of an incomplete circumferen-
tial resection. This difculty will lead to a greater chance
of persistent hemorrhoidal symptoms or bleeding.15
Grade 2/3 complication
Repair
Incomplete hemorrhoidal resection can be corrected
after stapling by excising remaining hemorrhoid in a
fashion analogous to the open technique.
Prevention
Placement of the pursestring with small travel between
the bites (total of six to eight bites), with care taken to
28 HEMORRHOIDECTOMY 311
Figure 288 The completed pursestring suture placed during a
PPH procedure, well above the dentate line.
keep the bites at the same level in the rectum, will
minimize the incidence of an incomplete doughnut and
the resulting incomplete resection of a quadrant.
Rectovaginal Fistula
An inappropriately deep pursestring suture may also
increase the possibility of a surgically created rectovaginal
or rectourethral stula when the stapler is red. This com-
plication is discussed later.
Postoperative Pain and Stricture
If the pursestring suture is placed too low in the distal
rectum or anal canal, the excision may take place in the
sensate portion of the anal canal, leading to unexpected
postoperative pain. Furthermore, low excision within the
anal canal may lead to postoperative stricture. Both of
these potential complications are discussed later.
Introduction of the Stapler and
Securing the Pursestring
Inadequate Excision
Consequences
Securing the pursestring suture through the stapler
once it is introduced is also critical to ensure adequate
hemorrhoidal excision. The stapler is introduced
into the rectum and the pursestring suture is secured
around the stem of the stapler. Once tied around
the shaft, the ends of the pursestring are then brought
out through the pursestring guides on the side of
the stapler and tied loosely together. Inadequate
tightening of the pursestring around the shaft of the
stapler may lead to an incomplete circumferential resec-
tion, causing persistent symptoms from remaining
hemorrhoids.
Grade 2 complication
 312 SECTION III: GASTROINTESTINAL SURGERY
Repair
Repair of an incomplete resection is treated by an
open excision of the remaining hemorrhoid, as noted
previously.
Prevention
Care when securing the pursestring around the shaft,
and upward traction on the loop of the pursestring
when the stapler is closed, will help prevent this
complication.
Closing and Firing the Stapler
Rectovaginal Fistula
Consequences
A surgically created rectovaginal stula (or, analogously,
a rectourethral stula in men) can occur if the
pursestring bites are too deep anteriorly, causing
full-thickness rectal wall excision when the stapler is
red. This is a disastrous complication of stapled
hemorrhoidectomy, which should be entirely avoidable
by adequate technique. It has, however, been
reported.16
Grade 3/4 complication
Repair
Primary surgical repair of the rectovaginal stula should
be performed if this complication is noted at the time
of surgery. This could be accomplished by a direct,
layered repair of the vagina, rectovaginal septum, and
rectal wall. Recognition of this complication postop-
eratively would require a delayed repair.
Prevention
Care needs to be taken to place the pursestring sutures,
especially anteriorly in women, only deep enough to
include the mucosa, submucosa, and hemorrhoidal
plexus. Prior to ring the stapler, the posterior vaginal
wall should always be palpated to ensure it is not
included in the staple line.
Excessive Postoperative Pain and Stricture
Consequence
If the pursestring suture is placed too low in the rectum
or anal canal or the stapler is positioned within the anal
canal, the excision will occur in an area of sensation for
the patient, near or below the dentate line. This will
result in unexpectedly high amounts of postoperative
pain, negating the reported advantages of decreased
postoperative pain associated with the stapling tech-
nique over the traditional surgical hemorrhoidectomy.
Furthermore, this may also lead to anal stenosis, owing
to the presence of the staple line in the narrowest part
of the anorectum, the anal canal.
Grade 2/3 complication
Figure 289 The PPH stapler in fully closed position, sitting well
within the rectum and anus, with only the 3- and 4-cm marks visible,
indicating an acceptably proximal position.
Repair
There is no specic initial repair of this problem once
the excision has occurred, and therapy is directed to
analgesic care. Symptomatic anal stenosis diagnosed in
the postoperative period would be treated by elective
anoplasty.
Prevention
Careful placement of the pursestring suture well into
the rectal vault, above the dentate line, will minimize
the likelihood of this complication. This adequate posi-
tioning is conrmed after the stapler is inserted and
closed. Prior to closure, only the 3- or 4-cm mark
should be visible at the anal verge. If the 1- or 2-cm
marks are visible, the stapler is too low in the anal canal
and should be repositioned (Fig. 289).
Removal of the Stapler and Inspection
of the Excision
Incomplete Excision
Consequences
Once red, the stapler should be loosened and removed.
The stapler should have two complete tissue dough-
nuts, analogous to the appropriately completed low
anterior stapled anastomosis. Incomplete doughnuts
may suggest an incomplete excision, leading to persis-
tent symptoms from the unexcised quadrant17 (Fig.
2810).
Grade 1/2 complication
Repair
If the incomplete excision is identied, that quadrant
may be simply excised by the open technique.

Figure 2810 Complete tissue doughnuts after PPH.
Prevention
As noted above, multiple (six to eight) bites placed
close together in the pursestring will help reduce this
problem. Careful inspection of the tissue excised and
the staple line will allow easy repair if it has occurred.
Postoperative Hemorrhage
Consequence
Staple line bleeding can occur, and failure to recognize
it at this point of the operation may result in the need
for reexploration in the early postoperative period.
Staple line bleeding will be more likely in patients with
incomplete tissue doughnuts.
Grade 2/3 complication
Repair
Identication of suture line bleeding at the time of
operation can be easily controlled by resuture ligation.
Substantial bleeding in the early postoperative period
requires reexploration.
Prevention
Careful staple line and tissue doughnut inspection will
prevent the morbidity of reoperation for early postop-
erative bleeding.
28 HEMORRHOIDECTOMY 313
REFERENCES
1. Shanmugam V, Campbell K, Louden M, et al. Rubber
band ligation versus excisional haemorrhoidectomy for
haemorrhoids. Cochrane Database of Systemic Review
2005;3:CD005034.
2. Shanmugan V, Thaha MA, Rabindranath KS, et al.
Systemic review of randomized trials comparing rubber
band ligation with excisional haemorrhoidectomy. Br J
Surg 2005;92:14811487.
3. Senagore AJ. Surgical management of hemorrhoids. J Gas-
trointest Surg 2002;6:295298.
4. Zaheer S, Reilly WT, Pemberton JH, Ilstrup D. Urinary
retention after operations for benign anorectal diseases.
Dis Colon Rectum 1998;41:696704.
5. Bailey HR, Ferguson JA. Prevention of urinary retention
by uid restriction following anorectal operations. Dis
Colon Rectum 1976;19:250252.
6. Hoff SD, Bailey HR, Butts DR, et al. Ambulatory surgical
hemorrhiodectomya solution to postoperative urinary
retention? Dis Colon Rectum 1994;37:12421244.
7. Lau H, Lam B. Management of postoperative urinary
retention: a randomized trial of in-out vs. overnight
catheterization. Aust N Z J Surg 2004;74:658661.
8. Goldberg SM. Hemorrhoids. In Goldberg SM, Gordon
PH, Nivatvong S (eds): Essentials of Anorectal Surgery.
Philadelphia: Lippincott, 1980; pp 4272.
9. Johannsen HO, Graf W, Pahlman L. Long-term results of
haemorrhoidectomy. Eur J Surg 2002;168:485489.
10. Gearhart SL. Symptomatic hemorrhoids. Adv Surg 2004;
38:167182.
11. Eu KW, Teoh TA, Seow-Choen F, Goh HS. Anal
stricture following haemorrhoidectomy: early diagnosis
and treatment. Aust N Z J Surg 1995;65:101103.
12. Neeklakandan B. Double Y-V plasty for post surgical anal
stricture. Br J Surg 1996;83:1599.
13. Mazier WP. Hemorrhoids, ssures, and pruritis ani. Surg
Clin North Am 1994;74:12771292.
14. Ferguson JA. Whitehead deformity of the anus, S-plasty
repair. Dis Colon Rectum 1979;22:286287.
15. Nisar PJ, Acheson AG, Neal KR, Scholeeld JH. Stapled
hemorrhoidopexy compared with conventional hemor-
rhoidectomy: a systematic review of randomized, con-
trolled trials. Dis Colon Rectum 2004;47:18371845.
16. McDonald PJ, Bona R, Cohen CR. Rectovaginal stula
after stapled hemorrhoidopexy. Colorectal Dis 2004;6:64
65.
17. Brusciano L, Ayabaca SM, Pescatori M, et al. Reinterven-
tions after complicated or failed stapled hemorrhoidopexy.
Dis Colon Rectum 2004;47:18461851.
29
Anal Fistulotomy
Eugene F. Foley, MD
INTRODUCTION
The surgical treatment of perianal stulous disease is one
of the most common, minor, benign anorectal procedures
performed by the general surgeon. Despite its frequency
and size, the appropriate balance between resolution of
the troubling symptoms of persistent stulas and the
potential for devastating functional consequences with
overly aggressive surgical treatment of stulas can be very
challenging. The major elements of successful anal stu-
lotomy surgery are described later, with emphasis on the
reduction of specic complications.
INDICATIONS
Although not all surgically drained perianal or perirectal
abscesses will result in a chronic stula-in-ano, it is esti-
mated that as many as 50% will.1 The symptoms of a
persistent stula include recurrent abscess formation,
chronic perianal drainage, and pain. The diagnosis of a
persistent stula-in-ano in most patients is an indication
for consideration of stulotomy to reduce or eliminate
these chronic symptoms and the frequency of recurrent
abscess formation. Notable exceptions would include
patients with complex stulas due to Crohns disease,
perineal radiation, or uncontrolled distal gastrointestinal
tract or gynecologic malignancy.
OPERATIVE STEPS
Step 1 Anesthetic considerations
Step 2 Examination and identication of internal
opening
Step 3 Assessment of sphincter complex in relation to
stula track
Step 4 Incision of stula
OPERATIVE PROCEDURE
Anesthetic Considerations
Urinary Retention
Urinary retention is one of the most common complica-
tions of all anorectal surgery. The extent and complexity
of surgery correlates with the incidence of this complica-
tion. A large institutional study has reported the incidence
of urinary retention after stula surgery as 5%.2
Consequences
Postoperative urinary retention may lead to the need
for urinary catheterization, delaying the discharge of
patients after this day-surgery procedure. It may also
require emergent reevaluation of the patient later in the
day after surgery.
Grade 1/2 complication
Repair
Urinary retention after anorectal surgery is treated by
temporary urinary catheterization, usually over a 24-
to 48-hour period. Conservative measures, including
voiding while submerged in a tub of warm water, may
avoid the need for catheterization. Formal urologic
evaluation is reserved for the minority of patients who
fail these measures, usually those with preoperative uro-
logic difculties.
Prevention
Judicious use of perioperative intravenous uid has
been shown to decrease this complication after hemor-
rhoidectomy.3,4 Although not conclusively shown in
the literature to reduce this rate after stula surgery,
analogous recommendations of limiting overdistention
of the bladder with excessive intravenous uid and
the liberal use of local anesthetic (bupivacaine [Mar-
caine]) to decrease postoperative levator spasm seem
reasonable.
Examination under Anesthesia and
Identication of the Internal Opening
Failure to Identify the Internal Opening
Finding the internal opening of the stula-in-ano is
the rst of two critical steps in the successful surgical treat-
ment of a stula. Benign stulas are the result of crypt-
glandular infection at the dentate line and are perpetuated
by a persistent internal opening at the inciting gland at
the dentate line.
 316 SECTION III: GASTROINTESTINAL SURGERY

Consequence
Failure to identify the internal opening of the stula-
in-ano will result in failure of the surgery to correct the
problem, resulting in persistent symptoms of recurrent
abscess formation or perianal drainage. Fistula surgery
should be successful in 85% to 90% of cases.5
Grade 2/3 complication
Repair
If the internal opening is not found, the external
opening and track should be opened and dbrided, to
improve drainage. Attempts at blindly cutting or forcing
the stula probe through the dentate line without
seeing an internal opening are unlikely to resolve the
stula and more likely to damage the underlying sphinc-
ter complex. If the internal opening is not identied or
opened, recurrent symptoms will likely mandate another
operative exploration at a later date.
Prevention
Several things may be done to facilitate identifying
the internal opening. It is important to be familiar with
Goodsalls rule, which describes the usual locations of Figure 291 Goodsalls rule predicting the location of the inter-
the internal opening of the stula based on the location nal opening of a stula-in-ano based on the location of the external
of the external opening. Goodsalls rule suggests that opening.
if the external opening is within 3 cm of the anal verge,
an external opening posterior to the midsagittal line
will generally course to a posterior midline internal
opening, whereas an anteriorly based external opening
will course radially on a straight line to its internal
opening (Fig. 291). Knowledge of this rule will help
immensely in concentrating ones search for the inter-
nal opening in the most likely location. With Goodsalls
rule in mind, most internal openings can be found by
simply passing a stula probe through the external
opening along the track and out the internal opening
(Fig. 292). If this proves difcult, many surgeons also
inject the external opening with a liquid substance such
as methylene blue or milk to help identify the internal
opening. Dilute hydrogen peroxide serves well in this
role, because it is easily seen on anoscopy and can be
repeated several times without staining the tissues the
way methylene blue does6 (Fig. 293).
Figure 292 A stula probe passed through the external opening,
coursing the stula, and entering the anal canal through the internal
Assessment of the Sphincter Complex in opening at the dentate line.
Relationship to the Fistula Track
Weakening of the Anal Sphincter these complications of stula surgery varies depending
and Incontinence on the study and degree of disability reported. Some
Once the internal opening is identied and the stula reports suggest the frequency of minor continence
probe is passed through the track, a careful assessment alterations to be as high as 30% to 50%.5,7,8 Major
of the amount of sphincter that will be cut with a stu- incontinence after stula surgery should be lower than
lotomy is made. This is the second key step in successful 10%.5,7,8
stulotomy. Grade 3 complication
Consequence Repair
Proceeding with a stulotomy in the presence of a high Permanent, disabling incontinence after stula surgery
or deep stula may result in temporary or permanent may be repaired by anal sphincteroplasty at an elective,
sphincter weakness and incontinence. The frequency of secondary surgery.9
 29 ANAL FISTULOTOMY 317

Figure 293 Hydrogen peroxide bubbling through the internal Figure 294 Identication of the sphincter complex cut at the
opening of a stula-in-ano after injection at the external opening. time of a transsphincteric stulotomy.

Prevention
Prevention of inadvertent sphincter injury causing
incontinence is an essential element of stula surgery,
and perhaps the most difcult to assess without sig-
nicant experience. It should be noted that many s-
tulas require some sphincter division and that many
transsphincteric stulas can be safely treated by stu-
lotomy. Furthermore, many factors contribute to how
much muscle can be safely cut, including preoperative
sphincter function, patient age, sex, and stula loca-
tion. Much less muscle can be safely cut in patients with
some preoperative weakness, older patients, and
women, particularly in anteriorly based stulas where
there is typically a very thin amount of sphincter
complex.10 In young, healthy men with a posteriorly
based stula, a stulotomy can safely be performed as
long as the puborectalis at the top of the sphincter Figure 295 The remaining, intact puborectalis at the top of the
complex is preserved. Recognition of the factors that sphincter left after a transsphincteric stulotomy.
make incontinence more likely and a conservative
approach to patients with these factors will reduce the
likelihood of this serious complication of stula stula as stulotomy and will be needed in only a minor-
surgery. ity of stula cases.
Generally, with the stula probe through the track,
the amount of muscle encompassed by the probe (which
Cutting the Fistulotomy
will be cut) and the amount of muscle deep to the probe
(which will be left) are palpated (Fig. 294). A determina- Once the internal opening is identied and the amount
tion regarding the safety of the stulotomy is then made of muscle to be cut is deemed safe, the stulotomy is
based on these ndings, the location of the stula, and created, typically by electrocautery. Chronic granulation
the preoperative factors listed previously. tissue is curetted from the track, and scar around the
If a surgeon is concerned about the depth of the stula internal and external openings is dbrided. The remaining
or the presence of risk factors for incontinence, a number intact sphincter is evaluated for adequacy (Fig. 295).
of techniques have been described to surgically treat the
high stula that do not involve cutting muscle.11 They
Persistent Fistula
include the use of a cutting seton, a Park stulectomy, the
use of brin glue, or a transanal sliding advancement ap. Consequences
Each of these techniques has proponents, although, in Inadequately opening and dbriding the track may lead
general, each is not typically as effective at resolving the to an increased rate of a persistent stula. Overag-
 318 SECTION III: GASTROINTESTINAL SURGERY
gressive muscle cutting leading to incontinence is dis-
cussed previously.
Grade 2/3 complication
Repair/Prevention
The repair and prevention of persistent stulas or anal
incontinence after stula surgery are discussed earlier.
REFERENCES
1. Vasilevsky CA, Gordon PH. The incidence of recurrent
abscesses or stula-in-ano following anorectal suppuration.
Dis Colon Rectum 1984;27:126130.
2. Zaheer S, Reilly WT, Pemberton JH, Istrup D. Urinary
retention after operations for benign anorectal diseases.
Dis Colon Rectum 1998;41:696704.
3. Bailey HR, Ferguson JA. Prevention of urinary retention
after operations for benign anorectal diseases. Dis Colon
Rectum 1976;19:250252.
4. Hoff SD, Bailey HR, Butts DR, et al. Ambulatory surgical
hemorrhoidectomya solution to postoperative urinary
retention?. Dis Colon Rectum 1994;37:12421244.
5. Garcia-Aguilar J, Belmonte C, Wong WD, et al. Anal
stula surgeryfactors associated with recurrence and
incontinence. Dis Colon Rectum 1996;39:723
729.
6. The American Society of Colon and Rectal Surgeons.
Practice parameters for treatment of stula-in-ano
supporting documentation. The Standards Practice Task
Force. Dis Colon Rectum 1996;39:13631372.
7. Gustafsson UM, Graf W. Excision of anal stula with
closure of the internal opening: functional and manomet-
ric results. Dis Colon Rectum 2002;45:16721678.
8. Cavanaugh M, Hyman N, Osler T. Fecal incontinence
severity index after stulotomy. Dis Colon Rectum
2002;45:349353.
9. Engel AF, Lunniss PJ, Kamm MA, Phillips RK. Sphinc-
teroplasty for incontinence after surgery for idiopathic
stula-in-ano. Int J Colorectal Dis 1997;12:323
325.
10. Billingham RP, Isler JT, Kimmins MH, et al. The
diagnosis and management of common anorectal disor-
ders. Curr Probl Surg 2004;41:586645.
11. Rickard MJ. Anal abscesses and stulas. Aust N Z J Surg
2005;75:6472.
Section IV
HEPATOBILIARY
SURGERY
Lynt B. Johnson, MD
Mistakes are a fact of life. It is the response to error that counts.Nikki Giovanni
30
Gallbladder: Cholecystectomy
(Laparoscopic vs. Open)
Amy D. Lu, MD
INTRODUCTION
Although Langenbuch reported the rst cholecystectomy
in 1882,1 it was not until 1905 that the rst complication
of bile duct strictures was reported by Mayo. Since then,
the numbers have continued to increase.2 Complications
in the open technique have been as low as 0.2% with train-
ing and the standardization of surgical technique.3 Two
techniques are used to perform a cholecystectomy. In the
retrograde method, the hilar structure dissection occurs
rst, followed by removal of the gallbladder. The ante-
grade or fundus-down approach separates the gallblad-
der from the liver before the duct and artery are ligated.
The antegrade technique is generally considered safer
because it allows for the progressive demonstration of
the anatomy down to the infundibulocystic junction. With
the improvement in the quality of ultrasound and the
innovation of laparoscopic technique, more patients are
being operated on, and laparoscopic cholecystectomy has
become the standard of care for cholelithiasis. Open cho-
lecystectomy is rarely performed anymore, usually when
laparoscopy fails. In this case, the conversion is because of
adhesions, bleeding, or anatomy.
However, with the increasing number of laparoscopic
cholecystectomies done, a parallel increase in complica-
tions has occurred.4,5 The most common complication
and also potentially the most devastating for the patient
are bile duct injuries. It has been reported that up to 40%
of the surgeons performing laparoscopic cholecystecto-
mies have caused a major bile duct injury and that the
early recognition of the injury affects outcome.6,7 Evi-
dence also suggests that outcome is improved if the inju-
ries are managed by an experienced hepatobiliary surgeon.8
Patients treated by the injuring surgeon have an increased
risk of death,9 yet between 50% and 75% of the complica-
tions are still repaired by the injuring surgeon.1012 With
the introduction of any innovative technique, there is a
period of evaluation and learning for surgeons to develop
the skill set required to perform the procedure. As the
technique becomes broadly accepted and utilization
increases, experience also increases and the learning process
is foreshortened. This is the case for laparoscopic chole-
cystectomy. When the laparoscopic technique was rst
introduced, only a few people were performing the pro-
cedure. As this innovation was found to be scientically
sound and benecial to the patient, more surgeons learned
the technique and it became widely adopted in the surgi-
cal community. Now, laparoscopic cholecystectomy is
routine in general surgical training; it is now being super-
vised and taught by experienced surgeons. The learning
 320 SECTION IV: HEPATOBILIARY SURGERY
curve variable has greatly diminished from the equation.
Because most bile duct injuries are perceived to be pre-
ventable, they are one of the most commonly litigated
surgical procedures in the United States.13 The most
common cause of bile duct injury is the misidentication
of the major duct for the cystic duct. Way and coworkers14
found the primary reason for the error to be a visual per-
ceptual illusion and not related to technical skill. The
argument follows then that most laparoscopic cholecys-
tectomy injuries do not meet the criteria for medical neg-
ligence. Monetary remuneration occurs when a physician
falls below the practice standard. Human error in laparo-
scopic cholecystectomies is not the result of purposeful
substandard performance, but rather, a consequence of
response to certain uncommon anatomic illusions.14 These
mistakes may be inevitable in high-risk technologic
settings.15 However, the further issue of diagnosis and
management may ultimately affect litigation. Other com-
plications may occur and may be related to the surgeons
operative experience.16 These complications include inju-
ries to the liver; less common are bowel and other vascu-
lar trauma.
Laparoscopic
Cholecystectomy
INDICATIONS
Biliary dyskinesia
Cholelithiasis
Cholecystitis with or without cholelithiasis
Gallbladder polyps
OPERATIVE STEPS
Step 1 Positioning and trocar placement
Step 2 Retraction of gallbladder
Step 3 Exposure, cholangiography, and ligation of
cystic artery and duct
Step 4 Dissection of gallbladder
Step 5 Removal of gallbladder
Step 6 Trocar removal
OPERATIVE PROCEDURE
Trocar Insertion
Trocar Insertion Injuries
Complications can be minimized by utilizing an open
technique with a Hassan port to rst enter the abdomen
for insufation at the umbilicus. The standard umbilicus
and epigastric ports are 10 to 12 mm in size, whereas two
other ports are 5 mm each. Before starting a laparoscopic
cholecystectomy, I usually mark the location for a subcos-
Traction applied
to gallbladder in a
superior direction only
Liver
Ill-defined CHD
biliary
anatomy
Lateral view:
Duodenum CHD behind cystic duct
Figure 301 The gallbladder being retracted.
tal incision. After entering the abdomen, try to place the
epigastric port along the subcostal line and enter the
abdomen to the right lateral aspect of the falciform liga-
ment. Next, the two remaining 5-mm ports should be
placed laterally to retract the gallbladder superiorly (Fig.
301). The patient should be positioned in reverse Tren-
delenburg. Complications for trocar insertion are dis-
cussed in Section I, Chapter 7, Laparoscopic Surgery.
Exposure, Cholangiography, and Ligation of
the Cystic Artery and Duct
Injury to the Common Bile Duct
Consequence
Serious morbidity and mortality can result. Studies
have shown the incidence of injury to be 0.1% to 0.5%
after the use of the laparoscopic approach.4,5 Jaundice,
biloma, biliary peritonitis, and sepsis can result earlier,
with later presentations of recurrent cholangitis and
secondary biliary cirrhosis. The level of the injury would
determine its grade of complication. Many classica-
tions have been used to attempt to delineate these
injuries. Bismuth rst classied bile duct strictures
based on the level of the stricture in relation to the
hepatic ducts. In an analysis of 252 cases, Way and
coworkers14 identied and classied four types of inju-
ries (Fig. 302 and Table 301) based on the mecha-
nism of the injury.
Grade 2/3/4/5 complication
Repair
Unfortunately, most injuries are not recognized at the
time of surgery. Therefore, biliary reconstruction in the
form of a hepaticojejunostomy is usually required. If
the injury is recognized at the time of surgery, conver-
sion to an open approach should be done to address
the injury. In some cases, a repair may be able to be
performed over a T-tube stent when there is no loss or
 30 GALLBLADDER: CHOLECYSTECTOMY (LAPAROSCOPIC VS. OPEN)
STEWART-WAY CLASSIFICATION
LAPAROSCOPIC BILE DUCT INJURIES
Class I Class II
Class III Class IV
Figure 302 Classication of laparoscopic bile duct injuries.
(From Way LW, Stewart L, Gantert W, et al. Causes and preven-
tion of laparoscopic bile duct injuries. Ann Surg 2003;237:460469,
by permission of the Annals of Surgery.)
Table 301 Mechanism of Injury
Class I CBD mistaken for cystic duct, but recognized
Cholangiogram incision in cystic duct extended into CBD
Class II Lateral damage to the CHD from cautery or clips placed
on duct
Associated bleeding, poor visibility
Class III CBD mistaken for cystic duct, not recognized
CBD, CHD, R, L hepatic ducts transected and/or resected
Class IV RHD mistaken for cystic duct, RHA mistaken for cystic
artery, RHD and RHA transected
Lateral damage to the RHD from cautery or clips placed
on duct
From Carroll BJ, Birth M, Phillips EH. Common bile duct injuries during
laparoscopic cholecystectomy that result in litigation. Surg Endosc
1998;12:310313, by permission of the Annals of Surgery.
damage of tissue and the repair will be tension free. If
the viability of the tissue is in any doubt, the best
approach would be to perform a Roux limb reconstruc-
tion. It is advisable in these repairs to temporarily stent
the bile duct.
Prevention
Identication of Rouvieres sulcus and dissection ventral
to this point ensures no unexpected anatomy and iden-
tication of signicant structures before ligation (Fig.
303). Also, utilization of a 30 telescope, avoidance
of diathermy near the common hepatic duct, dissection
close to the gallbladdercystic duct junction, and con-
version to the open approach when uncertain all
decrease the chance of injury. No dissection should
occur in the hepatoduodenal ligament at the base of
321
Cystic duct
Right hepatic
duct
Rouvieres sulcus
Figure 303 Rouvieres sulcus and the relationship of the right
hepatic duct.
segment IV because the left hepatic duct lies extrahe-
patically within this tissue. It may be helpful to divide
the cystic artery rst. This allows retraction of the
infundibulum laterally to better expose the cystic duct
junction with the bile duct. Early recognition of pos-
sible injury is also very important. When clipping the
presumed cystic duct, if a large clip does not fully
encompass the duct, one should reassess whether it is
in fact the cystic duct. During dissection, if one encoun-
ters the presence of another ductal structure or extra-
vascular structures, the common bile duct may have
been inadvertently perceived as the cystic duct. Con-
troversy exists as to whether intraoperative cholangio-
grams prevent bile duct injury.17,18 However,
intraoperative cholangiogram will likely identify the
injury at the time of surgery. Cholangiograms should
be used whenever the anatomy is confusing or biliary
anomaly is suspected (Box 301).
Injury to the Hepatic Artery
Consequence
Excessive bleeding may occur with uncontrolled tran-
section of an aberrant right hepatic artery or hepatic
ischemia with complete ligation and transection. Right
hepatic artery injury is most commonly associated with
injury to the right hepatic duct or with dissection under
the mistakenly identied common bile duct for the
cystic duct. If the patient has hepatic compromise (i.e.,
cirrhosis) or it is the main right hepatic artery, ligation
may lead to ischemia, liver failure, biloma, and/or
other biliary problems.
Grade 2/3/4 complication
 322 SECTION IV: HEPATOBILIARY SURGERY

Box 301 Rules of Thumb to Help Prevent Bile

Duct Injuries
Optimize Imaging
Use high-quality imaging equipment.

Initial Steps and Objectives

Before starting the dissection, use the triangle of Calot
for orientation; nd the cystic duct starting at the
triangle.
Pull the gallbladder infundibulum laterally to open the
triangle of Calot.
Clear the medial wall of the gallbladder infundibulum.
Make sure the cystic duct can be traced uninterrupted into
the base of the gallbladder.
Open any subtle tissue plane between the gallbladder and
the presumed cystic duct; the real cystic duct may be
hidden in there. Figure 304 The cystic artery (arrow) above the cystic duct.

Factors that Suggest One May Be Dissecting the

Common Duct Instead of the Cystic Duct
The duct when clipped is not fully encompassed by a
standard M/L clip (9 mm).
Any duct that can be traced without interruption to
course behind the duodenum is probably the common
bile duct.
Another unexpected ductal structure is present.
A large artery is behind the ductthe right hepatic artery
runs posterior to the common bile duct. Cystic artery
Extralymphatic and vascular structures are encountered in
the dissection.
The proximal hepatic ducts fail to opacify on operative
cholangiograms.

Obtain Operative Cholangiograms Liberally

Whenever the anatomy is confusing.
When inammation and adhesions result in a difcult
dissection.
Whenever a biliary anomaly is suspected; assume that what R. hepatic a.
appears to be anomalous anatomy is really normal and
confusing until proved otherwise by cholangiograms.
Cystic duct
Avoid Unintended Injury to Ductal Structures
Place clips only on structures that are fully mobilized; the Figure 305 The relationship of the right hepatic artery and
tip of a closed clip should not contain tissue. cystic duct.
The need for more than eight clips suggests the operation
may be bloody enough to warrant conversion to an open
procedure.
Consideration of a need for blood transfusion suggests
the operation should be converted to an open Repair
procedure. Conversion to an open approach is necessary for repair.
Open when inammation or bleeding obscures the An attempt may be made at end-to-end anastomosis
anatomy. unless an accessory artery is involved and collateral ow
is adequate.
Illusions
Compelling anatomic illusions to which everyone Prevention
is susceptible are the primary cause of bile duct The cystic artery normally lies above the cystic duct
injuries. Experience, knowledge, and technical skill (Figs. 304 and 305). It is important to identify the
by themselves are insufcient protection against this nal distribution of the artery into the gallbladder wall.
complication. A looped right hepatic artery may give rise to a short
cystic artery, which, if not identied, will lead to tran-
From Way LW, Stewart L, Gantert W, et al. Causes and prevention
of laparoscopic bile duct injuries. Ann Surg 2003;237:460469, by section of the right hepatic artery.
permission of the Annals of Surgery.
 30 GALLBLADDER: CHOLECYSTECTOMY (LAPAROSCOPIC VS. OPEN)
Dissection of the Gallbladder
Injury to the Liver
Consequence
Excessive bleeding. Anomalies in the position of the
gallbladder, such as an intrahepatic position, may make
the dissection of the gallbladder from its fossa difcult.
When the liver is enlarged or brotic, it may not be
pliable and will have a tendency to bleed when lifted
or manipulated. This is the case in cirrhotic and fatty
livers, in which it is difcult to retract the fundus over
the liver. Portal hypertension results in increased venous
collateralization and may make dissection dangerous.
Grade 1/2 complication
Repair
Cauterization of the liver bed for hemostasis.
Prevention
Identication of the plane of dissection. In patients
with portal hypertension, conversion to open is
prudent.
Perforation of the Gallbladder
Consequence
Spillage of bile or stones. Five percent to 40% incidence
in laparoscopic procedures, but complications occur
rarely. Complications can occur months to years after
the laparoscopic cholecystectomy. Isolated reports of
stone spillage resulting in abscess formation, sinus for-
mation, port site infections, and intestinal obstruction
have been described. Migration to other systems has
been documented,1921 resulting in hernia sacs and
stula. Recently, Zehetner and colleagues22 published
a review of the literature and case reports for lost gall-
stones and found the most frequent consequence was
an abscess in the abdominal wall.
Grade 1/2 complication
Repair
If possible, the hole in the gallbladder should be closed
by the grasp forceps or an endoclip. In case of spillage,
efforts should be made at stone retrieval and irrigation
of the peritoneal cavity to dilute any infected bile. Use
of a retrieval bag is recommended to prevent further
spillage. There is no indication for conversion to open
surgery.
Prevention
The incidence of perforation is higher in patients with
acute cholecystitis, especially when hydrops is present.
Aspiration of a tense gallbladder can facilitate dissec-
tion, and all attempts should be made to identify the
correct planes. If spillage occurs, patients should be
informed to minimize the legal implications and aid in
the diagnosis of later complications, should they
occur.
323
Bile Leaks
Consequence
Rarely, there may be leaks from the ducts of Lushka
(ducts draining directly from the liver into the gallblad-
der, not via the cystic duct). Bile leaks may also occur
from incomplete ligation of the cystic duct.
Grade 1/2 complication
Repair
None. May need persistent Jackson-Pratt drainage until
the ducts seal and may consider postoperative sphinc-
terotomy with endoscopic retrograde cholangiopan-
creatography (ERCP) to expedite the process. An
ERCP would be the procedure of choice for bile leaks.
It can be both diagnostic and therapeutic. If there is a
cystic duct leak, a stent can be placed across the leak
to facilitate closure. The ERCP would also identify
more serious pathology such as a common bile duct
injury.
Prevention
None. Examine the bed of the gallbladder carefully
prior to closing to determine the need for Jackson-Pratt
drain placement.
Trocar Removal
Trocar Site Hernias
These are described in Section I, Chapter 7, Laparoscopic
Surgery.
Other Complications
Hemobilia has been reported as a complication after lapa-
roscopic cholecystectomy.23,24 This complication has been
seen to occur usually within 4 weeks of the surgery, but
rare case reports of late onset have also been documented.25
The mechanism of injury is unclear, but thermal or
mechanical injury to the cystic or hepatic arteries and
common bile duct is the presumed pathogenesis. Patients
may require a combination of endoscopy and angiography
for diagnosis and management. In some case reports,
infection may have facilitated the stulization.26
Viscus injuries, especially duodenum or colon, are very
uncommon in laparoscopic cholecystectomy and are dis-
cussed in greater detail in Section I, Chapter 7, Laparo-
scopic Surgery. Although rare, they can be one of the
most lethal complications of laparoscopic surgery. Unfor-
tunately, these injuries are not usually recognized at the
time of surgery and are diagnosed later when patients
experience sepsis, peritonitis, or intra-abdominal abscess.
The late recognition of these injuries contributes to the
associated high mortality rates. The incidence of occur-
rence has been rare: around 0.1% to 0.4% of laparoscopic
cholecystectomy cases.27,28 Duodenal injuries have been
reported in laparoscopic cholecystectomies as a result of
thermal injury or laceration.29,30 Small bowel ischemia has
 324 SECTION IV: HEPATOBILIARY SURGERY

also been reported as an adverse affect of pneumoperito- Porcelain gallbladder

neum-associated intra-abdominal hypertension.31 This Mirizzis syndrome
results in the compromise of the mesenteric circulation.
Transient right shoulder pain is a common symptom after
laparoscopic cholecystectomy and is believed to be the OPERATIVE STEPS
result of a combination of the smoke, CO2, and uid.
However, persistent pain may be the rst sign of a missed Step 1 Incision
injury to the bowel. A high index of suspicion is necessary Step 2 Exposure of gallbladder
when the postoperative course is anything but routine. Step 3 Dissection of gallbladder
Step 4 Possible cholangiogram
Step 5 Ligation of cystic duct and artery
Open Cholecystectomy Step 6 Wound closure

Since the advent of laparoscopic surgery, open cholecys-

OPERATIVE PROCEDURE
tectomy procedures have been on the decline. However,
when such procedures are performed, it is usually the
Incision
result of conversion from the laparoscopic approach
because of anatomic difculties, excessive bleeding, or A right subcostal approach is taken. A midline incision is
complications. Acute and chronic inammation may also acceptable.
obscure anatomy. In these patients, the inammation
Bleeding from the Epigastric Vessels
may result in increased vascularity. In many cases of open
cholecystectomy, the gallbladder is severely inamed, and Consequence
an attempt to dissect the gallbladder from the liver may Bleeding may occur from the epigastric vessels during
not be easy. Utilization of the antegrade technique is the incision.
important in these surgically difcult situations. Opening Grade 1 complication
the fundus and introducing a nger into the gallbladder
are helpful to guide dissection. A portion of the wall Repair
may need to be left behind, and it is better to ligate the There is a rich collateralization in the abdominal wall,
cystic duct as close to the neck of the gallbladder as pos- so ligation of the epigastric vessels can be done with
sible to avoid injury to the common bile duct. Sometimes, impunity.
ligation of the neck is impossible to do and leaks occur.
A Jackson-Pratt drain should be left in the pouch for Prevention
drainage. These leaks will eventually seal. To avoid more Increased vascularity occurs in the setting of portal
serious complications, it is important in these cases to have hypertension, and therefore, these vessels may be quite
the pouch adequately drained to avoid formation of a large and require suture ligation.
biloma. Sealing of the leaks may be expedited with endo-
scopic stent placement in the common bile duct and
Exposure
occlusion of the cystic duct. ERCP can be performed with
sphincterotomy and provides both diagnostic and thera- A surgical pad placed behind the right lobe of the liver
peutic intervention. Small leaks of the ducts of Luschka can facilitate exposure.
will seal off rather quickly within a few days. Cystic duct
leaks may take several weeks. In those cases, a Jackson-
Dissection of the Gallbladder and
Pratt drain should be left in place for 6 weeks and then
Possible Cholangiogram
may be safely removed.
Injury to the Liver
See the section on Injury to the Liver, under Laparo-
INDICATIONS scopic Cholecystectomy, earlier.

Failed laparoscopic approach Perforation of the Gallbladder

Previous right upper quadrant surgery with hostile See the section on Perforation of the Gallbladder, under
environment Laparoscopic Cholecystectomy, earlier.
Gangrenous cholecystitis
Suspected gallbladder cancer

Ligation of the Cystic Duct and Artery

Other pathologic ndings (e.g., stula, hydrops)
Unclear anatomy
Failed ERCP with retained common bile duct stones
Suspected injury to bile duct, viscus, or major blood
vessel
In the open approach, antegrade dissection of the gall-
bladder allows for safe identication of the artery and
duct. By coming from lateral to medial as one approaches
the neck of the gallbladder and staying close to the gall-
 30 GALLBLADDER: CHOLECYSTECTOMY (LAPAROSCOPIC VS. OPEN)
bladder, identication and safe ligation of the appropriate
structures are facilitated.
Injury to the Hepatic Artery
See the section on Injury to the Hepatic Artery, under
Laparoscopic Cholecystectomy, earlier.
Injury to the Common Bile Duct
See the section on Injury to the Common Bile Duct,
under Laparoscopic Cholecystectomy, earlier.
Wound Closure
Wound Infection
A postoperative wound infection from this approach is
rare.
Consequence
Opening of the wound may be required and antibiotics
in the setting of cellulitis.
Grade 1 complication
Repair
Opening of the wound and packing.
Incisional Hernias
Consequence
Hernias may arise from poor closure technique.
Grade 3 complication
Repair
If there is no incarceration, the hernia can be repaired
electively or when symptomatic. Hernia repair in this
area will require mesh.
Prevention
Closure may be achieved as a two-layer closure;
however, previous right upper quadrant surgery may
necessitate a one-layer closure.
Combined
Cholecystectomy with
Liver Resection
Combined cholecystectomy with liver resection is per-
formed in many cases. Cholecystectomy is required for any
formal right or left hepatectomy, trisegmentectomy, or
bile duct tumor resections. These procedures are discussed
in Section IV, Chapter 32, Left Hepatectomy; Chapter
33, Trisectionectomy; and Chapter 39, Resection and
Reconstruction of the Biliary Tract. This section of this
chapter focuses on partial hepatectomy with cholecystec-
tomy. The most common indication for this procedure is
gallbladder cancer. Sometimes, it has been termed an
extended cholecystectomy. The extended cholecystectomy
325
Extent of node clearance
a
b
c
d
e
Figure 306 The nodal dissection around the porta hepatis.
involves en-bloc removal of adventitia and contained lym-
phatics surrounding the bile duct, portal vein, and hepatic
artery as well as excision of the liver substance adjacent to
the gallbladder bed (Fig. 306). Unfortunately, gallblad-
der cancer often presents too late for a curative resection
to be a viable option. However, about one third of the
cases of gallbladder cancer are found at the time of cho-
lecystectomy. When cancer is found, controversy still
exists about the optimum surgical procedure for treat-
ment. The spectrum of resections has included simple
cholecystectomy, nonanatomic wedge resection of the
gallbladder bed, formal removal of segments IV and V,
and combined liver resection with pancreaticoduodenec-
tomy.32 Wedge resection may seem to be the least radical
of the procedures, but it can be difcult and associated
with signicant blood loss because it is a nonanatomic
resection. Extended resections were once believed unnec-
essary for T2 tumors. These tumors by denition remain
subserosal but have invaded through the muscular layer.
However, the plane of dissection in a simple cholecystec-
tomy is in the subserosal plane between the liver and the
gallbladder, where tumor may be violated.33 Data have
shown that T2 tumors are also reported to have a high
incidence of regional nodal metastases from 33% to
43%.34,35 Improved 5-year survival of upward of 80% with
radical resection36,37 are seen compared with simple cho-
lecystectomy survival rates of 20% to 40%.38,39 When the
cancer has grossly penetrated the wall or locally advanced
disease is present, further controversy exists concerning
treatment. For tumors located in the fundus of the gall-
bladder, a radical cholecystectomy allows for an adequate
margin. However, when the tumors arise near the neck of
the gallbladder, in Hartmanns pouch or extend into the
hilum, there may be a role for an extended hepatectomy.40
 326 SECTION IV: HEPATOBILIARY SURGERY

Until recently, the operations for complete resection were

associated with a high incidence of morbidity, ranging
from 5% to 54%,41 and mortality rates up to 21%.27,42
However, several studies have shown surgical resection for
T3 or T4 tumors can result in long-term survival.40,43,44
During the late 1980s and 1990s, studies reported increas-
ing safety24 and an operative mortality of less than 5%,45
providing additional support for an aggressive approach
to gallbladder cancer utilizing an extended cholecystec-
tomy. A signicant number of gallbladder cancers will
present for denitive therapy after prior cholecystectomy.
There have been suggestions that patients subjected to
two operations have a less favorable prognosis than patients
with a single procedure. With experienced surgeons, the
outcome is sufciently favorable, and the outcome of
incomplete resection dismal, to warrant additional radical
resection. The resection must provide at least a 2-cm
margin of noninvolved liver tissue.

INDICATIONS

Early gallbladder cancer

Figure 307 The placement of chromic sutures for hemostasis
prior to transection of the liver parenchyma.
OPERATIVE STEPS

Step 1 Incision
Bleeding
Step 2 Exposure
Step 3 Transection of liver Consequence
Step 4 Ligation of cystic duct and artery As mentioned previously, because this is not an ana-
Step 5 Closure of wound tomic resection, bleeding can be more difcult to
control.
Grade 1 complication
OPERATIVE PROCEDURE
Repair
Incision
Parenchymal bleeding of the liver can usually be con-
A right subcostal approach is taken. trolled with direct cauterization; suture ligatures may
be needed with larger vessels.
Bleeding from the Epigastric Vessels
See the section on Bleeding from the Epigastric Vessels, Prevention
under Open Cholecystectomy, earlier. Careful dissection or use of large chromic sutures may
decrease the risk of serious hemorrhage (Fig. 307).
Exposure
Injury to the Hepatic Artery
A surgical pad placed behind the right lobe of the liver See the section on Injury to the Hepatic Artery, under
can facilitate exposure. Laparoscopic Cholecystectomy, earlier.

Transection of the Liver Bile Leak

A minimum of a 2-cm margin of healthy liver tissue should Consequence
be excised with the gallbladder. The plane of dissection While transecting liver, small bile ducts may be
can be initially demarcated with electrocautery or argon transected.
beam. With current improvements in instrumentation, Grade 1 complication
one can utilize various methods for parenchymal dissec-
tion including harmonic scalpel, Cavitron ultrasonic aspi- Repair
rator (CUSA), tissue link, or electrocautery. Suture ligation.
 30 GALLBLADDER: CHOLECYSTECTOMY (LAPAROSCOPIC VS. OPEN)
Prevention
Ligation of any vascular or duct structures while
transecting the parenchyma. A Jackson-Pratt drain
should be placed in order to drain the space if a bile
leak occurs. Usually, they will seal without further
intervention.
Ligation of the Cystic Duct and Artery
See the section on Ligation of the Cystic Duct and
Artery, under Open Cholecystectomy, earlier.
Nodal Dissection
The nodes around the porta hepatis should be removed
by skeletonizing the adventitia around the major struc-
tures. In this way, there is little risk of injury to any of the
structures in the porta hepatis.
Injury to the Common Bile Duct
See the section on Injury to the Common Bile Duct,
under Laparoscopic Cholecystectomy, earlier.
Injury to the Hepatic Artery
See the section on Injury to the Hepatic Artery, under
Laparoscopic Cholecystectomy, earlier.
Injury to the Portal Vein
Consequence
Immediate bleeding and possible ischemia to the
liver.
Grade 4/5 complication
Repair
Suture repair needs to be performed. A Pringle proce-
dure may need to be done in order to facilitate safe
repair of the vein. If there is tissue loss, one may need
to utilize a patch of vein as a graft.
Prevention
Careful identication of the anatomy. The portal vein
lies posterior to the hepatic artery and medial to the
common bile duct.
Closure of the Wound
Incisional Hernias
See the section on Incisional Hernias, under Open
Cholecystectomy, earlier.
Wound Infection
See the section on Wound Infection, under Open
Cholecystectomy, earlier.
327
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hepatic resection for gallbladder cancer. Am J Surg 2007;
194:355361.
41. Ogura Y, Mizumoto R, Isaji S, et al. Radical operations
for carcinoma of the gallbladder: present status in Japan.
World J Surg 1991;15:337343.
42. Donohue JH, Nagorney DM, Grant CS, et al. Carcinoma
of the gallbladder: does radical resection improve
outcome? Arch Surg 1990;125:237241.
43. Gall FP, Kockerling F, Scheele J, et al. Radical operations
for carcinoma of the gallbladder: present status in
Germany. World J Surg 1991;15:328336.
44. Onoyama H, Yamamoto M, Tseng A, et al. Extended
cholecystectomy for carcinoma of the gallbladder. World J
Surg 1995;19:758763.
45. Nakamura S, Sakaguchi S, Suzuki S, Muro H. Aggressive
surgery for carcinoma of the gallbladder. Surgery 1989;
106:467473.
31
Right Hepatectomy
Jay A. Graham, MD and Lynt B. Johnson, MD

INTRODUCTION right and left hepatectomies and provides a guide to

common pitfalls encountered during surgery. However,
In Le Foie: tudes Anatomiques et Chirurgicales, Claude much of the prevention strategies outlined in our chapter
Couinaud rst described the anatomic liver segments and are secondary to an inherent and thorough understanding
nomenclature widely used by surgeons today. His in- of the segmental liver anatomy.
depth understanding of the hepatobiliary anatomy helped
create the framework for much of liver surgery because it
provided a systematic approach for safe resection. The rst OPERATIVE STEPS
published hepatectomy was performed by Jean Louis
Lortat Jacob in 1952.1 Since then, the associated morbid- Step 1 Operative incision
ity and mortality have decreased tremendously. Improved Step 2 Division of falciform ligament
surgical technique using the roadmap laid out by Step 3 Division of right triangular ligament and coro-
Couinaud has undoubtedly been responsible for most of nary ligament with mobilization of right lobe of
the decline in operative complications. the liver.
In the last few years, surgeons have sought to bridge Step 4 Division of short hepatic veins between right
the gap between excellent operative technique and better hepatic lobe, caudate lobe (segments 1, 6, and
outcomes through the use of newer technology. One of 7), and inferior vena cava (IVC)
the main hurdles of liver surgery and predictors of poor Step 5 Cholecystectomy
outcomes is operative blood loss. Given the vascular nature Step 6 Extrahepatic dissection of porta hepatis
of the liver parenchyma, surgeons have employed many Isolation and division of right hepatic artery
devices intraoperatively to help identify and control large Isolation and division of right portal vein
vascular structures. Notably, ultrasound has emerged as Step 7 Isolation and division of right hepatic vein
an essential tool to assess the intraparenchymal liver Step 8 Hepatic parenchymal transection
anatomy intraoperatively. This provides the surgeon with Step 9 Intraparenchymal division of right hepatic duct
a powerful tool to evaluate the relationship between the
large vessels and the planned resection plane. Harnessing OPERATIVE PROCEDURE
ultrasonic energy, the ultrasonic dissector has also revolu-
tionized parenchymal dissection. Using ultrasonic energy A right hepatectomy involves resection of segments 5, 6,
to fragment liver tissue, this technique spares blood vessels, 7, and 8.
which are made of rmer brous tissue. Other devices
implement a pressurized jet of water to accomplish this Operative Incision
same task. The harmonic scalpel, which can be used to
Hernia
precisely cut and cauterize these vessels, also utilizes ultra-
sonic energy. Most recently, radiofrequency ablation has Consequence
emerged and been used in conjunction with surgery to The use of the Mercedes versus an extended right sub-
provide salvage therapy for large tumors. costal incision is a matter of surgical preference. Both
While the gamut of surgical instruments continues to give adequate visualization for a right hepatectomy
grow, certain core surgical principles remain relevant (Figs. 311 and 312). The midline incision extension
in the discussion of operative morbidity. The use of the to the xyphoid is often the site of hernia formation.
Pringle maneuver and measures taken to lower central Grade 3 complication
venous pressure (CVP) are two precepts that are proven
to minimize bleeding during resection. In this vain, this Repair
chapter proposes other techniques that can be used by the If the ventral hernia does not pose an incarceration risk,
hepatobiliary surgeon to reduce complication rates during it can be repaired electively or when symptomatic.
 330 SECTION IV: HEPATOBILIARY SURGERY
Figure 311 A right subcostal incision with a midline incision
gives adequate exposure to perform this operation.
D Consequence
B ligaments can lead to torsion, which can disrupt venous
C outow that leads to venous congestion and severe liver
A suspend the liver in anatomic position. After a right
Figure 312 Incisions for a right hepatectomy are depicted: A
B is a right subcostal incision, ABD is an extended right sub-
costal incision and ABC with BD is a chevron (Mercedes)
incision.
Prevention
A recent study comparing 856 patients with Mercedes
incisions with 570 patients with right subcostal inci-
sions demonstrated discrepancies with wound healing.
Patients with Mercedes incisions had a higher incidence
of hernias, 9.8% versus 4.8%.2 However, any incision is
prone to herniation without proper surgical technique
with regard to reapproximation of the fascia.
Persistent Bleeding from the Superior
Epigastric Arteries
Consequence
The superior epigastric arteries are invested in the
rectus muscle near the xiphoid and can be lacerated
during upper transverse incisions. These vessels can
bleed signicantly if they are not controlled.
Grade 1 complication
Repair
There is a rich collateral bed of vessels in this area.
Therefore, ligation of the superior epigastric arteries is
permissible.
Prevention
Surgical exposure is paramount during this operation.
Therefore, these vessels can be sacriced for optimiza-
tion of the surgical view.
Division of the Falciform and Left
Triangular Ligaments
Torsion of the Left Lobe
Extended division of the falciform and left triangular
dysfunction. The left triangular ligament helps to
hepatectomy, the left lobe tends to rotate into the right
subphrenic space. Excessive left triangular ligament
division can exacerbate this occurrence and lead to
torsion. Therefore, it is prudent to maintain the left
triangular ligamentous attachments.
Grade 4/5 complication
Repair
A study that analyzed 44 right hepatic resections
concluded that venous outow was improved when the
left lobe was placed in its original anatomic position.3
Thus, it is recommended that after a right hepatec-
tomy, the left lobe of the liver should be xed into
anatomic position.
Prevention
When possible, an excessive division of the falciform
ligament, and especially the left triangular ligament,
should be avoided to prevent exacerbation of venous
outow obstruction. If the left lobe shifts from ana-

Figure 313 The divided falciform ligament is reapproximated
to secure the left lobe of the liver using 4-0 Prolene.
tomic position after a right lobe hepatectomy, it is
advisable to secure the remnant (Fig. 313).
Other options are to mobilize the hepatic exure and
allow the right colon to partially ll in the space.
Injury to the Suprahepatic IVC
Consequence
Great care should be taken when cutting the falciform
ligament as one approaches the bare area of the liver.
The vena cava lies just posterior to the inferior edge of
the falciform ligament and may be readily injured with
aggressive dissection.
Grade 5 complication
Repair
The vena cava should be immediately repaired to
prevent further blood loss and possible air embolus.
The rst rule is do not panic.
The surgeon should tamponade the injury by placing
the index nger of the nondominant hand over the
hole.
Using 4-0 Prolene, place whip stitches until the hole is
closed.
Avoid using clamps to control the bleeding because this
will often tear the vessel wall, causing bigger problems.
Make an effort to get good visualization of the injury.
Placing errant sutures can often lead to narrowing or
obstructing the lumen of the vessel
Prevention
The surgeon should be aware of the anatomy in this
area to prevent inadvertent injury to the vena cava.
It is imperative that patients undergoing a right hepa-
tectomy have adequate central venous access to monitor
CVP and for resuscitation as necessary.
In the event of moderate blood loss, preoperative autol-
ogous blood donation, intraoperative cell savage, and nor-
31 RIGHT HEPATECTOMY 331
Figure 314 The dome of the right liver has been exposed by
careful dissection of the right triangular and coronary ligaments.
The blue rubber tie is placed around the right hepatic vein. The
inferior vena cava (IVC) is located posterolateral to this blue rubber
tie. The surgeon must be mindful of this structure when dissecting
the ligamentous attachments.
movolemic hemodilution have been shown to minimize
the use of banked blood.4
Division of the Right Triangular Ligament and
the Right Side of the Coronary Ligament with
Mobilization of the Right Lobe of the Liver
Injury to the Right Hepatic Vein or
Suprahepatic IVC
Mobilization of the right lobe of liver begins with dissec-
tion through the lateral peritoneal reection of the right
triangular ligament. This dissection is carried medially
through this relatively avascular areolar tissue plane. Supe-
rior mobilization of the right lobe involves taking down
the right coronary ligament. As the dissection proceeds
medially, care should be taken to avoid injury to the right
hepatic vein or the IVC in the bare area of the liver.
Consequence
Dissection through the superior and medial aspects of
this avascular tissue can lead to inadvertent injury to
the right hepatic vein or IVC. Transection of the right
hepatic vein without ligation poses a serious problem
because the surgeon is confronted with controlling a
large hole in the IVC without adequate exposure.
Grade 5 complication
Repair
Any bleeding that is encountered should be controlled
and the defect closed with suture.
Prevention
Again, meticulous dissection in the medial aspects of
the coronary ligament can prevent inadvertent venoto-
mies (Fig. 314). One of the rare complications with
 332 SECTION IV: HEPATOBILIARY SURGERY

injury to these large veins can be air embolism. During

this stage of the operation, it has been proposed that
the patient have a positive CVP and be placed in Tren-
delenberg position to prevent air embolus. However,
with increased CVP, bleeding will increase.

Injury to the Diaphragm

Diaphragm puncture can occur with dissection of the
infradiaphragmatic plane of the right triangular ligament.
Also, sometimes intentional diaphragmatic resection is
necessitated by liver tumors that are adherent to the
diaphragm.
Consequence
Diaphragmatic injury can occur during dissection of
the bare area of the liver. When this occurs, negative
pleural pressure is lost and must be restored.
Grade 1/2 complication Figure 315 A right-angle clamp is inserted under the edge of
triangular ligament to safely facilitate the dissection of the right lobe
Repair of the liver from the diaphragm.
Negative pleural pressure needs to be reestablished
during the operative case after violation of the thoracic
cavity. All diaphragmatic holes can be repaired primar-
ily using a nonabsorbable suture. One technique that
is readily used in our hospital to restore a normal pul-
monary environment is the use of a small catheter with
suction. A red rubber catheter with suction is placed in
the defect, and a pursestring suture is cinched down as
the catheter is quickly removed.
Prevention
Careful dissection of the peritoneal reections of the
posterior liver while an assistant rotates the liver medi-
ally and inferiorly may decrease the incidence of dia-
phragmatic injury.
The central portion of the diaphragm is often stretched
thin owing to large right lobe tumors. When this occurs,
the triangular ligament is draped over the right lobe and
Figure 316 The location of the duodenum can obscured by
is much higher than anticipated. A right-angle clamp
omental fat (). Electrocautery should be used sparingly when
inserted under the edge will allow the surgeon to safely dissecting in this plane. The arrow demonstrates the portal vein.
identify the insertion of the ligament and the capsule of
the liver (Fig. 315).
Prevention
Duodenal Injury Electrocautery should be used sparingly in the inferior
aspects of the triangular ligament because the duode-
Consequence
num may be injured.
Duodenal injuries can occur while dissecting in the
inferior planes of the right triangular ligament. The
Injury to the Adrenal Gland
duodenum usually sits away from the right triangular
ligament so that gentle retraction with a nger can Consequence
protect its integrity. However, a duodenum that sits in The adrenal gland may also be injured with dissection
a more cephalad position may be more prone to injury. in the right coronary avascular planes. An adrenal
Dissection of the triangular ligament around the right hematoma due to injury of the parenchyma is a known
renal peritoneal reection can place the duodenum at consequence of right hepatectomy.5
risk (Fig. 316). Grade 1 complication
Grade 1/2 complication
Repair
Repair The adrenals are rarely the site of major blood loss,
Simple duodenal lacerations may be repaired primarily and these hematomas can be followed up with serial
with a monolament suture. imaging.6

There is tremendous collateral circulation to the adrenal
gland. Therefore, any problematic vessels can be oversewn
without severe consequence.
Prevention
The medial reections of the right coronary ligament
should be divided close to the liver to avoid injury to
the adrenal glands. Once renal fascia is encountered,
the surgeon should direct his or her dissection in an
anterior fashion. Of note, once the adrenal gland is
visualized, the IVC is very nearby.
Recognition of the Phrenic Vessels
Consequence
In dividing the right triangular ligament, it is not
uncommon to come across suprarenal and phrenic
vessels as they drain their respective structures. There
is adequate collateralization of the inow and outow
to the diaphragm and adrenal gland. Therefore, these
vessels can be ligated and divided as the surgeon con-
tinues in superomedial dissection.
Grade 0 complication
Repair
No repair is needed because these vessels may be
divided.
Prevention
The bare area of the liver must be followed closely
when dissecting the coronary ligaments to prevent
phrenic vessel injury.
Division of the Short Hepatic Veins Between
Segments 1, 6, 7, and the IVC
Mobilization of the right lobe reveals short hepatic veins
that may be ligated and divided as they come off of the
Figure 317 Rolling the liver medially, one can appreciate the
ligation of the short hepatic veins between segments 1, 6, 7, and
the IVC ().
31 RIGHT HEPATECTOMY 333
IVC (Fig. 317). Their division allows greater mobility of
the right liver lobe. IVC injury can occur during this
portion of the operation, and management of this injury
is detailed previously.
Injury to the IVC with Division of the
Ligamentous Band of the Caudate Lobe
Consequence
In many patients, a ligamentous band attaches the
Spieghel portion of the caudate lobe to segment 7 of
the liver (Fig. 318). This attachment passes postero-
lateral to the IVC and can contain liver parenchyma.
This band must be divided in order to mobilize the
right liver.
Grade 5 complication
Repair
This ligamentous band often contains liver parenchyma
and separate venous drainage. This band must be
divided, ligated, and oversewn.
Prevention
Special care must be taken when dividing this struc-
ture, given the immediate proximity of the IVC (Fig.
319).
Cholecystectomy
The gallbladder is taken down in standard dome-down
fashion. Complications are detailed in Section IV, Chapter
30, Gallbladder: Cholecystectomy (Laparoscopic vs. Open).
Extrahepatic Dissection of the Porta Hepatis
Extrahepatic dissection of the porta hepatis is a popular
method for inow control. However, hilar dissection can
put contralateral structures at risk through devasculariza-
tion or injury.
Figure 318 The Kelly clamp illustrates the parenchymal
connection between the Spiegel portion of caudate lobe and
segment 7.
 334 SECTION IV: HEPATOBILIARY SURGERY

Ligamentous Bare area

band
Inferior vena
cava
Caudate
Renal
lobe
impression

Portal vein Left

gastric a.
Proper hepatic
artery Proper
hepatic a. Left
hepatic a.
Right
replaced
hepatic a
Colic impression

Segment IV
Figure 319 The ligamentous band between the caudate lobe
and segment 7 of the liver is clearly seen. When dividing this band,
the surgeon must be mindful of the proximity of the IVC.
For this reason, we do not advocate extrahepatic bile
duct division. Moreover, with extrahepatic biliary dissec-
tion, the surgeon may place the common hepatic duct in
jeopardy.
Common Hepatic Duct Vascular Compromise
Consequence
Attempts to nd the conuence of the right and the
left hepatic ducts in the hilum often necessitate dissec-
tion around the common bile duct. The vascular supply
of the common hepatic duct runs along this structure
at the 3 and 9 oclock positions. Therefore, minimal
dissection of this crucial structure should ensue when
attempting to isolate the right hepatic duct.
Grade 1/2/3 complication
Repair
Common hepatic duct vascular compromise leading
to stenosis is often manifested with pain, increasing
bilirubin, and possible cholangiitis.7 Radiographic
studies usually will demonstrate intrahepatic bile duct
dilatation. The stenosis can usually be endoscopically
stented with good results. However, when endoscopic
stenting fails, the injury must be addressed with a
Roux-en-Y hepaticojejunostomy.8,9
Figure 3110 The lateral position of a replaced right hepatic
artery with regard to the portal triad.
Division of the Right Hepatic Artery
Recognition of the Replaced Right
Hepatic Artery
Consequence
The right hepatic artery usually courses posterior to the
common hepatic duct. A multitude of anatomic vari-
ants are present in the right hepatic arterial vasculature,
the most common being the replaced right hepatic
artery (Fig. 3110).
Grade 0 complication
Repair
No repairs are needed because all right-sided hepatic
anomalous arteries should be divided to ensure safe
transection of the liver parenchyma.
Prevention
The prevalence of a replaced right hepatic artery is
approximately 17%.10 Intraoperative assessment by pal-
pation of the portal triad helps to identify a replaced
right hepatic artery (Fig. 3111). A pulse posterolateral
to the common hepatic duct should raise suspicions for
this anomalous artery.

Prevention Division of the Right Portal Vein

Some surgeons advocate performing a cholecystectomy
Injury to the Left Portal Vein
and extrahepatic dissection of the common hepatic
duct to trace its bifurcation. However, we prefer intra-
parenchymal right hepatic duct division to prevent
common hepatic duct vascular disruption. Typically,
the bifurcation of the hepatic ducts is situated under
segment 4. It is safer to divide the bile duct in the
parenchymal division phase of the operation rather than
to try and isolate this structure outside the liver.
Consequence
All attempts to maintain the luminal diameter of the
left portal vein branch should be taken to ensure ade-
quate venous ow. The right branch of the portal vein
is very short, and careless ligation can encroach upon
the left portal vein, causing stenosis.11
Grade 1/2 complication

Figure 3111 The right-angle clamp clearly demonstrates a
replaced right hepatic artery lateral to the portal vein, which is being
lifted by a vein retractor. Also, nger palpation of the proximal
replaced right hepatic artery is being demonstrated with the right
index nger.
Figure 3112 A malleable retractor has been positioned under
segment 4 to allow the hilar shelf to move caudally. Next, a vein
retractor is used to lift the common hepatic duct and expose the
right portal vein (arrow). The right hepatic artery () has been
divided prior to this portion of the operation.
Repair
Usually, short segments of stenosis will not impede the
venous ow sufciently to cause lasting morbidity.
However, if the portal vein to the left portal vein
conduit is deemed to be inadequate (signicantly small
diameter), it should be revised.
Prevention
Segment 4 should be elevated, and the hilar shelf will
move caudally, giving the surgeon a better operative
view (Fig. 3112). Care must be taken to clearly iden-
tify the bifurcation before extrahepatic division.
31 RIGHT HEPATECTOMY 335
Figure 3113 Hilar shelf elevation with a vein retractor demon-
strates the caudate venous supply from the right portal vein (suture
encircling).
Use a vein retractor to lift the common duct so that the
bifurcation can be adequately visualized. The ligation of
the right portal vein should not cause stenosis of the
segment between the main and the left portal veins.
Injury to the Posterior Portal Vein Feeding
the Caudate Lobe
Consequence
Given the short segment of extrahepatic right portal
vein, meticulous dissection is needed to preserve portal
vein ow to the caudate lobe.
Grade 1 complication
Repair
Usually, there is adequate arterial collateralization to
the caudate lobe to ensure viability. Therefore, no
repair is needed if the posterior portal venous ow to
caudate lobe is interrupted. However, most liver sur-
geons believe that it is better to preserve this caudate
lobe blood supply.
Prevention
The right portal vein usually gives off a branch that
feeds the caudate lobe (Fig. 3113). This branch lies
posterior to the bifurcation of the right and left portal
veins. Injury to this structure may occur with dissection
of a short right portal vein in the posterior planes.
When attempting to circumscribe the right portal vein,
the surgeon must be aware of the portal vein supply of
the caudate lobe (Fig. 3114).
Left-sided Gallbladder
Left-sided gallbladder describes the two anatomic variants
in which the gallbladder lies against the left segments or
is characterized by a right-sided round ligament. In the
 336 SECTION IV: HEPATOBILIARY SURGERY
Ligamentous
band
Caudate
lobe
Caudate
branches
of portal v.
Portal vein
Figure 3114 Right and left portal veins are shown to give off
branches to the caudate lobe. The surgeon should be familiar with
this anatomy so as to preserve blood ow to the caudate lobe and
to minimize bleeding.
latter variant, the gallbladder lies in a normal position but
the round ligament is on the right, giving the appearance
of a left-sided gallbladder.12 Left-sided gallbladders are
worrisome because of the anatomic challenges they
provide.
Consequence
The presence of a left-sided gallbladder heralds the
potential of biliary and portal venous variation.13 The
left and right hepatic ducts usually converge at
the hepatoduodenal ligament. This also holds true for
the left and right portal veins. However, in patients
with left-sided gallbladders, care must be taken when
dividing the liver parenchyma. In this situation, the left
portal vein takeoff is more distal in position, and injury
can occur if it is not recognized. Also, the left hepatic
duct may traverse through a portion of the right
lobe.
Grade 1/2/3 complication
Repair
An injury to the left-sided portal venous vasculature
may signicantly compromise the vascular supply
of the remaining left lobe. If a major portal venous
injury is encountered, immediate vascular repair must
ensue with either primary anastomosis or venous patch
angioplasty.
If the left hepatic duct is injured and cannot be repaired
primarily, a Roux-en-Y hepaticojejunostomy will need to
be done.
Prevention
Dissection of liver parenchyma should be done care-
fully to identify all structures. In this situation, the
surgeon must carry out dissection on the right side of
the gallbladder to prevent unwarranted portal vein or
hepatic duct injury.
Isolation and Division of the Right Hepatic Vein
The right hepatic vein is the largest of the three veins and
drains most of the right lobe of the liver. Identication
and ligation can be done either during or before paren-
chymal division. We prefer to identify and divide the right
hepatic vein before parenchymal transection to minimize
backbleeding through the venous tributaries. Our approach
is to divide the right hepatic vein with an endovascular
gastrointestinal anastomosis (GIA) stapler.
Hepatic Vein Bleeding
Consequence
Brisk bleeding can arise from the right hepatic vein if
it is not clamped and ligated properly.
Grade 1 complication
Repair
Stump bleeding from the right hepatic vein can
occur after its division. Usually, this is secondary to a
ligation tie that is improperly placed. Using 4-0 Prolene,
the defect can be whip stitched until the hole is
closed.
Prevention
Adequate right hepatic vein length should be obtained
via hepatic parenchyma resection prior to ligation and
division.
Hepatic Parenchymal Transection
Blood Loss
Consequence
Through the years, blood loss has been responsible for
the signicant morbidity associated with this operation.
Given the vascular nature of the liver and that this
organ receives 25% of the cardiac output; hepatic resec-
tion often leads to a signicant blood loss.
In an attempt to lessen blood loss intraoperatively,
many surgical instruments have been employed in the
operative theater. Today, parenchymal division is usually
accomplished by using a Cavitron ultrasonic surgical
aspirator (CUSA), harmonic scalpel, or saline-enhanced
cautery (Figs. 3115 to 3117). These instruments have
been shown to decrease blood loss.14 However, even with
these instruments, the surgeon can encounter signicant
blood loss. Increased blood loss mandates transfusion
and places the patient at risk for blood-borne infections,
shock, and in some series, increased risk of recurrence in
malignancies.
Grade 1/3/4/5 complication
 31 RIGHT HEPATECTOMY 337

Repair
In patients with catastrophic uncontrolled hemorrhage
or with tumors that require reconstruction of the IVC,
total vascular occlusion can be employed.15 This tech-
nique involves placing clamps across the infradiaphrag-
matic IVC, infrahepatic IVC, and portal triad. In
addition, the right adrenal vein must be ligated in order
to achieve total vascular isolation.
Prevention
In the early 1900s, Hogarth Pringle described an inow
occlusion technique to limit blood loss during liver
surgery.16 The Pringle maneuver requires that the vas-
cular structures in the hepatoduodenal ligament be
temporarily occluded. This technique has been used by
surgeons for close to 100 years, and one study veried
that it reduced blood loss.17 In patients with chronic
Figure 3115 Parenchymal division proceeds in anterior to pos-
liver disease, intermittent occlusion is often used to
terior plane using a Cavitron ultrasonic aspirator (CUSA). The small
intraparenchymal vessels are cauterized with the Bovie.
prevent signicant ischemia times.
Decreasing the CVP during a hepatectomy can lower
blood loss.18 In a prospective, randomized, controlled
trial, 25 patients underwent hepatectomies with a CVP of
2 to 4 mm Hg, while the control group underwent the
same operation but with higher CVPs. On average, the
control group lost approximately 600 ml more blood than
the group with low CVPs.19
Isovolemic hemodilution (IH) can be used to reduce
the transfusion requirement during hepatic resection. IH
is safe, and its use is reported to result in a 60% reduction
in mean packed red blood cell transfusion.20 Adverse
effects of homologous blood transfusions are well docu-
mented, and IH may be implemented to lessen the asso-
ciate risks.

Intraparenchymal Division of the Right

Hepatic Duct
Bifurcation of the common hepatic duct lies in the poste-
Figure 3116 Larger vessels are clipped or tied.
rior aspect of segment 4. We believe that it is much safer
to identify this structure during intrahepatic parenchymal
dissection between segments 4 and 5.

Bile Leak
Figure 3117 The cauterized left lobe of the liver can be seen
after completion of the right hepatectomy.
Consequence
Biliary leakage is a serious consequence after right or
left hepatic division during major hepatic resections.
Leaks more often occur at the cut surface of the liver
parenchyma but can also present secondary to inade-
quate ligation of the hepatic ducts.21
Grade 1/2 complication
Repair
Several approaches have been used to manage a bile
leak after major hepatic resection. Endoscopic retro-
grade cholangiopancreatography with stenting has
been shown to be very effective for biliary control, but
it is only necessary if the leak is greater than 100 ml for
longer than 7 days. More minor leaks will often seal.
 338 SECTION IV: HEPATOBILIARY SURGERY
Prevention
Meticulous attention to bile staining of the cut edge of
the liver will direct the surgeon to areas that may leak
bile. If a leak is seen, it should be oversewn.
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Della Rovere G (eds). Liver Surgery. Padua, Piccin
Medical Books, 1982; pp 2332.
12. Nagai M, Kubota K, Kawasaki S, et al. Are left-sided
gallbladders really located on the left side? Ann Surg
1997;225:274280.
13. Regimbeau JM, Panis Y, Couinaud C, et al. Sinistroposi-
tion of the gallbladder and the common bile duct.
Hepatogastroenterology 2003;50:6061.
14. Wu W, Lin XB, Qian JM, et al. Ultrasonic aspiration
hepatectomy for 136 patients with hepatocellular carci-
noma. World J Gastroenterol 2002;4:763765.
15. Huguet C, Nordlinger B, Galopin JJ, et al. Normothermic
hepatic vascular exclusion for extensive hepatectomy. Surg
Gynecol Obstet 1978;147:689693.
16. Troitskii RA. Current aspects of liver surgery. Review of
the literature. Eksp Khir Anesteziol 1965;4:4850.
17. Man K, Fan ST, Ng IO, et al. Prospective evaluation of
Pringle maneuver in hepatectomy for liver tumors by a
randomized study. Ann Surg 1997;226:704713.
18. Jones RM, Moulton CE, Hardy KJ. Central venous
pressure and its effect on blood loss during liver resection.
Br J Surg 1998;85:10581060.
19. Wang WD, Liang LJ, Huang XQ, Yin XY. Low central
venous pressure reduces blood loss in hepatectomy. World
J Gastroenterol 2006;14:935939.
20. Johnson LB, Plotkin JS, Kuo PC. Reduced transfusion
requirements during major hepatic resection with use of
intraoperative isovolemic hemodilution. Am J Surg 1998;
176:608611.
21. Reed DN, Vitale GC, Wrightson WR, et al. Decreasing
mortality of bile leaks after elective hepatic surgery. Am J
Surg 2003;185:316318.
32
Left Hepatectomy
Jay A. Graham, MD and Lynt B. Johnson, MD

INTRODUCTION
In regard to the performance of a left hepatectomy, the
operative concepts remain unchanged from that of a right-
sided resection. While technically easier than a right hep-
atectomy, the detailed understanding of liver anatomy
is paramount to reproducibly performing safe left-sided
hepatectomies. Moreover, the surgical pitfalls we discuss
should prompt a thorough examination of hepatic anato-
my as it relates to form and function to prevent the forth-
coming outcomes.
INDICATIONS
Division of the Falciform Ligament
The falciform ligament and ligamentum teres should be
divided so that the left lobe can be fully mobilized.
Division of the Left Triangular and
Coronary Ligaments
Injury to the Phrenic Vessels
As the phrenic vessels course along the diaphragm in an
oblique fashion, they can be inadvertently transected
during dissection of the left coronary ligaments (Fig. 32
1). During this phase of left lobe mobilization, it is best
to hug the surface of the liver. See Section IV, Chapter
31, Right Hepatectomy.

Benign tumors (e.g., hepatic adenoma or symptomatic

Injury to the Inferior Vena Cava
hemangioma)
Malignancies Consequence
Primary liver cancer (hepatoma or cholangiosarcoma) During division of the coronary and left triangular
Metastases ligaments, the inferior vena cava (IVC) may be injured
with medial dissection.
Grade 5 complication
OPERATIVE STEPS
Repair
Step 1 Operative incision Management is discussed in Section IV, Chapter 31,
Step 2 Division of falciform ligament Right Hepatectomy.
Step 3 Division of left triangular and coronary
ligaments Prevention
Step 4 Division of hepatogastric ligament Dissection of the coronary ligaments should be done
Step 5 Ligation and division of left hepatic artery and with great care to minimize the chance of an inadver-
left portal vein branch tent IVC puncture.
Step 6 Liver parenchymal division
Step 7 Left hepatic duct division
Esophageal Injury
Step 8 Middle and left hepatic vein division
Consequence
The esophagus lies at the inferior edge of the triangu-
lar ligament (Fig. 322). Esophageal injury may occur
OPERATIVE PROCEDURE
during stray dissection in this area.
Grade 2/3 complication
Operative Incision
Typically, a right subcostal or chevron incision with Repair
midline extension is used to provide excellent exposure Unrecognized esophageal injuries can be catastrophic.
during a left hepatectomy. Therefore, the esophagus should be inspected carefully
 340 SECTION IV: HEPATOBILIARY SURGERY

and primarily repaired immediately if an injury is found.

Drains should be left in the vicinity and the patient
kept on postoperative antibiotics that target enteric
organisms.
Prevention
The left triangular ligament should be taken down at
the peritoneal reection of the left lobe. Dissecting
along the inferior edge of the liver should keep the
surgeon superior to the esophagus. A right angle can
be used to pull the triangular ligament and peritoneal
attachments away from crucial structures during this
mobilization.

Division of the Hepatogastric Ligament

Figure 321 The left coronary and triangular ligaments have
been divided to reveal the bare area of the liver (). The left phrenic
vein () is prominent and observed to be coursing through this
area. After dividing the left coronary and triangular ligaments, the
surgeon rotates the left lobe medially to reveal the remnant of the
ligamentum venosum as it enters the left hepatic vein just cephalad
to the caudate lobe ().
Injury to an Accessory or Replaced
Left Hepatic Artery
An accessory or replaced left hepatic artery branches off
the left gastric artery. The aberrant artery lies in the hepa-
togastric ligament and can be injured during dissection
(Fig. 323). The incidence of this anomaly is approxi-
mately 12.5%.1
Consequence
Uncontrolled bleeding may result from inadvertent
transection of an aberrant left hepatic artery traveling
in the hepatogastric ligament.
Grade 1 complication

Left triangular
lig.

Right triangular Esophagus

lig.
Abdominal
aorta

IVC

Figure 322 The proximity of

the left triangular ligament with the
esophagus. The surgeon must be
aware of this spatial anatomy
to avoid inadvertent esophageal
injury during left triangular ligament
division.

Right
hepatic a.
Proper
hepatic a.
Figure 323 A replaced left hepatic artery
should be recognized and controlled before divi-
sion of the hepatogastric ligament to avoid poten-
tial bleeding.
Repair
The aberrant left hepatic artery must be ligated to stop
any potential hemorrhage. If necessary, the left gastric
artery can be sacriced to control bleeding.
Prevention
Inoperative assessment with palpation can delineate any
structures that lie within the hepatogastric ligament.
The hepatogastric ligament should be palpated for an
aberrant left hepatic artery prior to division.
Gastric Perforation
Consequence
The stomach is tented against the liver by the hepato-
gastric ligament. Division of the tissue is often carried
parallel to the lesser curve of the stomach, and injury
may result.
Grade 1 complication
Repair
If a gastric injury is noted, the opening should be pri-
marily repaired immediately. An omental patch can be
placed to bolster the repair.
Prevention
Angle the plane of dissection to hug the left lobe of
the liver. Injury to the left lobe of liver is of no conse-
quence since it will be resected.
Ligation and Division of the Left Hepatic
Artery and the Left Portal Vein Branch
The portal triad is easily viewed lying under the hilar plate
of the quadrate segment, and the inow vessels can be
32 LEFT HEPATECTOMY 341
Left gastric a.
Left replaced
hepatic a.
MC
controlled. Once the hilar plate is retracted superiorly, rst
palpate to conrm normal hepatic artery anatomy or
replaced variants. The adventitial tissue above the hepatic
artery can be divided to expose the vessel. It is imperative
that the surgeon trace back the surmised left hepatic artery
to the common hepatic artery to avoid inadvertent injury
to the right arterial supply.
To gain access to the portal vein, lift the bile duct with
a vein retractor to expose the left portal vein.
Caudate Portal Vein Injury
Consequence
The left portal vein may give off a branch that feeds
the caudate lobe. Ligation of the left portal vein prox-
imal to this vein will cut off the portal venous supply
to the caudate lobe.
Grade 1 complication
Repair
Whereas the ligation of the left portal vein in this area
is not ideal, there should be sufcient inow to the
caudate lobe from arterial vessels.
Prevention
The caudate lobe portal venous supply can be preserved
if the ligation of the left portal vein is distal to this
branch. Every attempt should be made to adequately
dissect the left portal vein before division to ensure
salvation of the caudate portal inow. If dissection is
difcult, dividing the left portal vein at the umbilical
ssure can be done, because the caudate portal vein is
usually proximal to this point (Figs. 324 and 325).
 342 SECTION IV: HEPATOBILIARY SURGERY

Liver Parenchymal Division response subsides in the postoperative period, gastric

Delayed Gastric Emptying
Consequence
Delayed gastric emptying is a known complication of
left hepatectomy as the stomach contacts the surface of
the cut liver. Delayed gastric emptying usually presents
with early satiety, decreased appetite, weight loss, and
nausea and vomiting.
Grade 1 complication
Repair
In our clinical practice, gastric emptying is a rare entity
seen after left hepatectomy. Although the clear cause is
not understood, it is assumed that the postoperative
inammatory mediators from the cut surface of the
liver decrease gastric motility. As the inammatory
Figure 324 The caudate vein (blue tie) coming from the left
portal vein. The surgeons index nger is placed on the caudate
lobe for anatomic reference.
motility usually returns to normal.
If delayed gastric emptying persists, a specialist in gas-
troenterology should be involved to rule out mechanical
obstruction and to help with possible prokinetic medical
therapy.
Prevention
A recent study purports that tacking the omentum to
the peritoneum prevents delayed gastric emptying by
reducing stomach and liver contact.2 However, there is
no clear consensus on the best preventive therapy.
Gastric Volvulus
Consequence
Mesenteroaxial gastric volvulus has been described after
left-sided hepatic resections. The clinical presentation
is variable, but often, the patient presents with symp-
toms related to a chronic intermittent gastric outlet
obstruction. In the living related donor, the occurrence
is reported as 11%.3
Grade 3 complication
Repair
Mesenteroaxial volvulus has been described in partial
lobectomy or complete transplantation of the liver.4
Typically, gastric volvulus can be managed with non-
operative therapy, including proton pump inhibitors,
nasogatric tube suction, and attempted reduction
via endoscopy.5 If the patients symptoms persist or
the clinical presentation deteriorates, exploratory
laparotomy with gastropexy should be done. Vascular
compromise is uncommon in mesenteroaxial gastric
volvulus, so the need for resection of nonviable stomach
is rare.
Prevention
Mesenteroaxial gastric volvulus associated with left
hepatectomy is almost certainly associated with division

Caudate
lobe outline
Branches to
caudate lobe

Portal vein

Figure 325 The caudate lobe venous supply is shown.


Right
hepatic duct
Common
hepatic duct
A B
Figure 326 A, Hilar hepatic duct division is fraught with potential risks owing to the prevalence of biliary anatomic aberration. Intra-
parenchymal division of the left hepatic duct improves the chance that injury will be avoided. B, An aberrant dorsal caudal branch of the
right hepatic duct is shown.
of the hepatogastric ligament. However, division of this
structure is inevitable with left-sided liver resection.
Therefore, patients should be counseled with regard to
the risk of this potentially chronic problem and correc-
tive surgery. There is no precedent in the literature to
perform gastropexy at the time of liver resection, and
we do not employ this technique in our practice because
we believe the risks outweigh the benets.
Left Hepatic Duct Division (Fig. 326)
Injury to the Aberrant Dorsal Caudal Branch of
the Right Hepatic Duct
Whereas some groups advocate division of the left hepatic
duct during hilar dissection, we do not use this technique.
Biliary anatomic aberration poses potentially disastrous
complications to the liver surgeon. We believe these risks
are signicantly minimized by opting to divide the left
hepatic duct during liver parenchymal division, rather than
at the hilum.
Consequence
The biliary system is prone to anatomic variation. These
variations can be problematic in patients undergoing a
left hepatectomy. Aberrant posterior right hepatic ducts
that drain into the left hepatic duct in the intrahepatic
32 LEFT HEPATECTOMY 343
Aberrant dorsal
caudal branch
of the right
hepatic duct
Left hepatic
duct
Common
hepatic duct
umbilical ssure are estimated at 11%.6 A closed biliary
system can arise if this type of anatomy is encountered.
Division of the left hepatic duct proximal to the aber-
rant posterior right hepatic insertion will result in an
open posterior right biliary system.
Grade 3 complication
Repair
In general, if the injury is signicant, a Roux-en-Y right
hepaticojejunostomy must be created in order to drain
the right posterior segmental of the biliary tree. Other
options include attempted primary anastomosis with a
T tube, but these surgical reconstructions often have a
high rate of failure. If the duct is less than 2 mm, often
simple ligation can be employed. Closure may lead to
atrophy of the corresponding posterior right segments.
Prevention
We believe that the left hepatic duct should be divided
during parenchymal division to avoid unintentional
biliary tract injury. We believe this approach gives the
surgeon the best opportunity to correctly identify the
left hepatic duct. Moreover, biliary branches traveling
in the left lobe encountered during parenchymal division
are likely to solely feed the left lobe. The same cannot
be said for biliary branches traversing the hilum.
 344 SECTION IV: HEPATOBILIARY SURGERY
Middle and Left Hepatic Vein Division
Many liver surgeons prefer extrahepatic control of the
hepatic veins prior to parenchymal division. Whereas sur-
gical preference dictates the techniques used for control
of the hepatic veins, we believe that employment of intra-
operative ultrasound and intraparechymal division confers
many advantages. Namely, the liver surgeon can avoid
difcult dissection and isolation of the hepatic veins, espe-
cially the left hepatic vein that typically joins the middle
hepatic vein within 2 cm of the IVC.
Injury to the IVC
See Section IV, Chapter 31, Right Hepatectomy.
Injury to the Spleen
Overaggressive mobilization and rotation of the left lobe
anterior and to the right prior to complete division of the
left triangular ligament can lead to inadvertent splenic
tears.
Consequence
During mobilization of the left hepatic lobe in a medial
and anterior fashion, ligamentous attachments may
avulse the spleen.
Grade 4 complication
Repair
Splenic injury necessitates either splenorrhaphy or
splenectomy to control bleeding. Capsular tears can
sometimes be repaired by placing surgical ties over the
injury and welding them in place with the argon beam
coagulator.
Prevention
Splenic avulsion can be prevented by ensuring that all
posterolateral peritoneal reections to the spleen are
divided prior to mobilizing the liver.
REFERENCES
1. Varotti G, Gondolesi GE, Goldman J, et al. Anatomic
variations in right liver living donors. J Am Coll Surg 2004;
198:577582.
2. Yoshida H, Mamada Y, Taniai N, et al. Fixation of the
greater omentum for prevention of delayed gastric empty-
ing after left-sided hepatectomy: a randomized controlled
trial. Hepatogastroenterology 2005;65:13341337.
3. Akamatsu T, Nakamura N, Kiyosawa K, et al. Gastric
volvulus in living, related liver transplantation donors and
usefulness of endoscopic correction. Gastrointest Endosc
2002;55:5557.
4. Franco A, Vaughan KG, Vukcevic Z, et al. Gastric voluvlus
as complication of liver transplant. Pediatr Radiol 2005;35:
327329.
5. Wasselle JA, Norman J. Acute gastric volvulus: pathogen-
esis, diagnosis, and treatment. Am J Gastroenterol 1993;8:
17801784.
6. Cheng YF, Huang TL, Chen CL, et al. Anatomic dissocia-
tion between the intrahepatic bile duct and portal vein: risk
factors for left hepatectomy. World J Surg 1997;21:297
300.
33
Trisectionectomy
John E. Scarborough, MD,
Carlos E. Marroquin, MD, Bryan M. Clary, MD,
and Paul C. Kuo, MD, MBA
INTRODUCTION
Trisectionectomy is the most extensive hepatic resection
procedure possible, short of total hepatectomy in prepara-
tion for orthotopic liver transplantation. Left trisectionec-
tomy, also called extended left hepatectomy, involves the
resection of the left hepatic segments (2, 3, and 4) as well
as the right anterior sector (segments 5 and 8). Resection
of the caudate lobe (segment 1) is also occasionally
included in this procedure. Right trisectionectomy, also
referred to as extended right hepatectomy, involves resec-
tion of the right lobe of the liver (segments 5, 6, 7, and
8) as well as segment 4 of the left lobe. These extensive
procedures are primarily indicated in patients with
extremely large hepatocellular carcinomas involving both
hepatic lobes, large hepatoblastomas in pediatric patients,
and centrally located (hilar) cholangiocarcinomas. Trisec-
tionectomy has also been described in case reports for the
management of a variety of metastatic lesions and for a
host of benign hepatic diseases.
As experience with hepatic resection has evolved since
the late 1980s, signicant improvements in perioperative
morbidity and mortality have been realized. Nonetheless,
because it involves the resection of up to 70% to 80% of
functional hepatic mass, trisectionectomy places patients
at considerable risk for postoperative morbidity. In a study
of over 1800 liver resections performed at Memorial
Sloan-Kettering from 1991 to 2001, investigators found
that the incidence of postoperative morbidity and mortal-
ity increased signicantly as the number of segments
involved in the resection increased. For patients undergo-
ing trisectionectomy at that institution, the complication
rate of 75% and operative mortality rate of 7.8% were
signicantly higher than for patients undergoing less
extensive resections.1 When the same authors analyzed a
subgroup of 226 patients undergoing only extended
hepatic resections, they were able to identify a total of ve
factors that were most predictive of in-hospital mortality:
cholangitis, creatinine greater than 1.3 mg/dl, total bili-
rubin greater than 6 mg/dl, intraoperative blood loss
greater than 3 L, and vena caval resection.2 The presence
of any two of these factors was associated with 100%
mortality, whereas the absence of any of these factors
was associated with only 3% mortality. In the largest series
of left hepatic trisectionectomies published to date, from
Nishio and colleagues,3 revealed an overall morbidity rate
of 46% and a 30-day mortality rate of 7%. Preoperative
jaundice and intraoperative blood transfusion were identi-
ed by multivariate analysis to be the major risk factors
for postoperative morbidity in this group of 70 patients.
Knowledge of the variables most predictive of postop-
erative morbidity has stimulated a number of modica-
tions in the preoperative and intraoperative management
of patients undergoing extended hepatic resection. Preop-
erative management options such as portal venous embo-
lization and biliary drainage, as well as intraoperative
techniques aimed at limiting blood loss, have enabled
trisectionectomy to be performed with minimal periop-
erative mortality and major postoperative morbidity. One
analysis of 58 major hepatic resections, including 49 tri-
sectionectomies, reported 0% perioperative mortality and
a 43% morbidity rate, with no cases of postoperative liver
failure.4 Other groups are reporting similar outcomes,
indicating that trisectionectomy for oncologic diagnoses
can be performed with minimal short-term mortality.5,6
INDICATIONS
Large hepatocellular carcinoma involving bilateral
hepatic lobes
Large hepatoblastomas (pediatric patients)
Hilar cholangiocarcinomas involving bilateral hepatic
ducts
Metastatic tumors to liver involving bilateral hepatic
lobes (e.g., colorectal metastases)
OPERATIVE STEPS COMMON TO
BOTH RIGHT AND LEFT
TRISECTIONECTOMY 7
Step 1 Diagnostic laparoscopy to detect unresectable
disease
Step 2 Incision: bilateral subcostal incision with midline
extension to xyphoid process
 346 SECTION IV: HEPATOBILIARY SURGERY

Step 3 Abdominal exploration and intraoperative ultra- to caudate branch, depending on whether caudate
sonography of hepatic lesions and major vascular lobe to be included in resection)
structures Step 8L Control of outow vessels (middle and left
Step 4 Mobilization of liver hepatic veins)
Step 5 Conrmation of arterial anatomy via palpation Retract left liver to patients right after division of
of gastrohepatic ligament and gastroduodenal lesser omentum
ligament to rule out accessory/replaced hepatic Identify and divide ligamentum venosum between
arteries caudate lobe and back of segment 2
Step 6 Ligation of cystic duct and artery, Individual division of left and middle hepatic veins
cholecystectomy using vascular stapler
Step 7 Control of inow vessels via extrahepatic dissec- Step 9L Parenchymal transection
tion and ligation Plane of transection is lateral to gallbladder fossa and
Step 8 Control of outow vessels anterior to main right hepatic venous trunk halfway
Step 9 Parenchymal transection between right anterior and posterior pedicles
Step 10 Closure of abdominal wall in one or two layers
and skin closure
OPERATIVE PROCEDURE

OPERATIVE STEPS SPECIFIC TO
RIGHT TRISECTIONECTOMY
Step 7R Control of inow vessels via extrahepatic dis-
section and ligation
Open sheath of porta hepatis, dissection of plane
between common bile duct and portal vein, ligation
and division of right portal vein, ligation and divi-
sion of right hepatic artery
Dissection of umbilical ssure to identify vascular
pedicles to segments 2, 3, and 4. Identication, liga-
tion, and division of hepatic arterial and portal
venous branches to segment 4
Step 8R Control of right hepatic vein
Division of right triangular ligament to completely
mobilize right lobe off retroperitoneum
Ligation/division of small hepatic venous tributaries
from caudate process and posterior aspect of right
lobe to inferior vena cava (IVC)
Isolation, ligation, and division of right hepatic
vein
Isolation, ligation, and division of middle hepatic
vein
Step 9R Parenchymal transection
Plane of transection is to immediate right of
falciform ligament, starting from anterior surface
and proceeding back toward divided right hepatic
vein
OPERATIVE STEPS SPECIFIC TO
LEFT TRISECTIONECTOMY
Step 7L Control of inow vessels via extrahepatic dis-
section and ligation (see Fig. 331)
Dissection of umbilical ssure to identify, ligate, and
divide left hepatic artery
Identication, ligation, and division of left portal
vein at base of umbilical ssure (proximal or distal
Skin Incision
Inadequate Exposure
The standard skin incision used for trisectionectomy is
the bilateral subcostal incision with extension of the
midline cephalad toward the xyphoid process. In special
cases, however, this incision may not provide optimal
exposure. This is especially true for redo hepatic resections
involving the right hepatic lobe, for large tumors in the
superior portions of the right or left hepatic lobes, or
when the IVC requires dissection above the level of the
diaphragm.
Consequence
Difculty in hepatic venous identication and control
owing to inadequate liver mobilization increases the
potential for hepatic venous injury and subsequent
massive hemorrhage.
Grade 5 complication
Repair
Maximizing the position of a self-retaining retractor
may permit better visualization of the suprahepatic and
retrohepatic IVC.8 In cases in which manipulation of
the retractor still does not provide adequate exposure,
extension of the subcostal incision further to the right
or left may help to improve exposure. Rarely, creating
a modied thoracoabdominal incision permits exposure
to the chest and supradiaphragmatic vena cava and may
be especially useful in patients with bulky tumors of the
superoposterior portions of the right hepatic lobe,
especially in large patients.9
Prevention
An alternative to the bilateral subcostal incision is an
upper midline incision from the xyphoid process to
2 cm superior to the umbilicus connecting to a right
transverse abdominal incision extending to the midax-
illary line halfway between the lowest rib and the right
iliac crest.7 This incision usually provides sufcient

exposure for all types of hepatic resection, including
resections involving the right lobe of the liver. A right
anterolateral thoracoabdominal incision will permit
access to both the chest and the abdominal cavity and
should be considered preoperatively either in patients
with a large tumor of the right lobe or in those who
require repeat resection after a previous right hepatic
lobectomy. In the Memorial Sloan-Kettering series of
over 1800 hepatic resections, a thoracoabdominal inci-
sion was required in only 3% of patients.1
Mobilization of the Liver
Postoperative Pleural Effusion
Pleural effusion is one of the most common complications
after major hepatectomy and likely has a multifactorial
etiology. A retrospective review of 254 patients undergo-
ing liver resection for hepatocellular carcinoma at one
institution found the incidence of patients developing
postoperative intractable pleural effusion to be 5.9%.10
The pressure differential between the abdominal and the
thoracic spaces, combined with compromise of the dia-
phragmatic barrier owing liver mobilization, can cause
ascitic uid to traverse the diaphragm and accumulate in
the right pleural space. Patients with some degree of
underlying cirrhosis are also commonly hypoalbuminemic
and may also have high portal venous pressures that are
transmitted to the azygous vein, thus promoting transuda-
tion into the pleural space.11
Consequence
Although often asymptomatic, postoperative pleural
effusions may compromise the respiratory function of
posthepatectomy patients. The effusion can cause pul-
monary atelectasis and poses a risk factor for nosoco-
mial pneumonia. In patients on the ventilator, signicant
pleural effusion can increase the number of days that
mechanical ventilation is necessary, whereas in patients
who have already been extubated, pleural effusion may
increase the incidence of reintubation.
Grade 2 complication
Repair
Intraoperatively, pleural drainage using an indwelling
central venous catheter in the pleural cavity has been
shown to be efcacious in preventing the accumulation
of pleural uid after hepatectomy.12 Postoperative
drainage for pleural effusion is indicated either in
patients who are experiencing difculty weaning from
mechanical ventilation or in those who have marginal
respiratory function postextubation. Management
options include diuretic administration, pleural drain-
age via either thoracentesis or a pleural drainage cath-
eter, and pleurodesis. In a study of 10 patients with
postoperative pleural effusion, 4 responded to conser-
vative management with diuretics, 4 required pleural
drainage, and 2 required pleurodesis.11
33 TRISECTIONECTOMY 347
Prevention
Multivariate analysis of patients with intractable pos-
thepatectomy pleural effusion revealed increased serum
levels of type IV collagen, preoperative transcatheter
arterial embolization, and resections including seg-
ments 7 and/or 8 to be independent risk factors for
the development of this complication.10 A separate
investigation conrmed that resections involving
segments 7 and 8, via either right hepatectomy or
posterior segmentectomy, led to increased risk of post-
operative pleural effusion.13
The difference between the positive pressure of the
abdominal cavity and the negative pressure of the intra-
thoracic space may contribute to the unidirectional
diffusion of ascitic uid into the pleural space, especially
as the dissociation of the liver from its diaphragmatic
attachments can lead to an increase in the development
of small holes in the diaphragm. Simply extending the
duration of postoperative mechanical ventilation by 1
day postoperatively has been shown to reduce the
development of pleural effusion after hepatectomy, pre-
sumably by providing persistent positive intrathoracic
pressure to allow brin deposits to seal the small diaphrag-
matic communications between the abdomen and the
thoracic cavity and thus preventing the migration of ascitic
uid.14
Alternatively, argon beam coagulation of the dissected
diaphragmatic surfaces may help to seal these tiny routes
for uid migration intraoperatively. Yan and colleagues12
compared two groups of hepatectomy patients, one who
underwent separation of the liver from the diaphragm
using argon beam coagulation and the other undergoing
suture ligation of bleeding points from the diaphragmatic
attachments. Patients in the argon beam coagulation
group had a 3.8% incidence of postoperative pleural effu-
sion, whereas patients in the suture ligation group had a
10.5% incidence (P < .01). In a separate prospective, ran-
domized trial of 60 patients undergoing hepatectomy, 28
underwent argon beam coagulation of the cut surface of
the hepatic ligaments and bare area of the retroperito-
neum whereas 32 did not. The two groups of patients
were similar with respect to demographic characteristics
as well as preoperative and postoperative liver function.
One of the 28 patients receiving argon beam coagulation
developed postoperative pleural effusion at 3 days postop-
eratively compared with 9 of the 32 patients who did not
receive argon beam coagulation.11
An alternative to the use of argon beam coagulation is
to apply brin sealant to the cut surface of the diaphrag-
matic attachments after liver mobilization. This technique
resulted in a signicant reduction in the development of
postoperative pleural effusion among 25 patients under-
going hepatectomy compared with a control group of 39
patients in whom brin sealant was not used.15 Avoidance
of routine use of the thoracoabdominal approach to liver
resection has also been suggested as a means to reduce
the incidence of postoperative pleural effusion and the
 348 SECTION IV: HEPATOBILIARY SURGERY
necessity for subsequent thoracentesis because up to 73%
of patients in whom this incision is used will develop
pleural effusion postoperatively.16
Control of Inow Vessels
Hepatic Necrosis due to Hepatic Arterial or
Portal Venous Injury or Thrombosis
Because trisectionectomy involves the removal of a large
majority of functional hepatic mass, injury to any of the
major structures that provide vascular inow to the
remnant liver can have severe consequences.
Consequence
The hepatic artery is responsible for up to 50% of the
oxygen supply to the liver. Because the oxygen con-
sumption is expected to be elevated after hepatectomy
as the remnant liver undergoes regeneration, compro-
mise of oxygen delivery to the remnant liver owing to
hepatic arterial injury can result in acute necrosis of the
remaining hepatic tissue. In addition, compromise of
the portal venous ow postoperatively can also result
in hepatic necrosis because the portal vein normally
provides 75% of blood ow to the liver. Acute hepatic
necrosis is typically characterized by acute abdominal
pain and abrupt, marked increases in transaminase
levels. Other sequelae of fulminant hepatic failure may
soon follow. The diagnosis can be conrmed by duplex
ultrasonography, which will document reduced or
absent hepatic arterial or portal venous ow and
hypoechogeneic areas within the remnant liver. Com-
puted tomography can verify the absence of portal ow
and arteriography can verify the absence of hepatic
arterial ow, if ultrasound is equivocal.17
Grade 4 complication
Repair
Injuries to the hepatic artery or portal vein that are
recognized intraoperatively can usually be repaired.
Hepatic arterial injuries that do not involve excessive
segment lengths can be repaired using a direct end-to-
end anastomosis or a saphenous vein interposition
graft. Portal venous injuries, meanwhile, can usually be
repaired by venoplasty using the greater saphenous
vein. Vascular reconstruction of either the hepatic
artery or the portal vein in patients undergoing hepatic
resection for cholangiocarcinoma has been shown to
result in survival rates comparable with those in patients
who do not require such reconstruction.6
Unrecognized hepatic arterial injuries that lead to
hepatic arterial thrombosis postoperatively are usually not
necessary to repair because the resulting hepatic necrosis
is irreversible. However, in order to maximize the func-
tion of the remaining liver tissue, some groups have
reported performing portal arterialization in these situa-
tions. This procedure involves the construction of a shunt
between the portal vein and a mesenteric artery, thereby
increasing the delivery of oxygen to regenerating hepatic
tissue that is spared of necrosis.17,18
Prevention
The best way to prevent hepatic arterial injury is to have
a thorough knowledge of variants to normal hepatic
arterial anatomy and to carefully assess the anatomy of
individual patients through preoperative multisection
computed tomographic arteriography. Normal
hepatic arterial anatomy, which is present in only 55%
of patients, consists of a common hepatic artery coming
off of the celiac axis, giving off a gastroduodenal branch
to then become the proper hepatic artery.19 The proper
hepatic artery travels toward the liver within the hepa-
toduodenal ligament, lying anterior to the portal vein
and to the left of the common bile duct. In up to 20%
to 30% of patients, a left hepatic artery arises from the
left gastric artery. This can be either an accessory left
hepatic artery (which occurs in addition to a left branch
of the proper hepatic artery) or a replaced left hepatic
artery (which represents the sole arterial supply to the
left segments of the liver). In approximately 17% of
patients, a right hepatic artery arises from the superior
mesenteric artery. This artery, which can also serve as
either an accessory or a replaced right hepatic artery,
travels within the hepatoduodenal ligament posterior
to the common bile duct, then to the right of the
common hepatic duct as it approaches the hilum of
the liver.20
Portal venous anatomy tends to be more consistent
from patient to patient, although variants do exist. The
portal vein lies posterior to both the common bile duct
and the hepatic artery within the hepatoduodenal liga-
ment. The most common anomaly requiring attention
during left trisectionectomy is trifurcation of the portal
vein, in which the portal vein branches to the right para-
median and lateral sectors originate from the main portal
vein in addition to the left portal vein.21 In patients with
a normal portal vein bifurcation undergoing left trisectio-
nectomy, care must be taken in dissecting the right portal
vein because this branch is much shorter than the left
portal vein (Fig. 331).
In addition to thorough knowledge of these types of
variants, avoiding injury or excessive manipulation of the
hepatic artery and portal vein that is to supply the remnant
liver is also essential for preventing postoperative hepatic
necrosis owing to hepatic arterial injury. For example,
when performing a Pringle maneuver, a tourniquet made
from a Penrose drain to obtain vascular inow occlusion
should be used in order to avoid intimal disruption within
the proper hepatic artery that can be caused by direct
application of vascular clamps.17 In addition, verication
of pulsatile blood ow to the planned hepatic remnant
during occlusion of arterial inow into liver to be resected
will assist in prevention of this complication.

Left hepatic duct
Right hepatic duct
Gall bladder
Figure 331 Isolation of hepatic
arterial and portal venous inow of the
planned resection. Careful dissection of Cystic duct
the left hepatic artery, and left portal Common hepatic duct
vein is critical in order to prevent
damage to the vascular inow of the Common bile duct
remnant liver. The point of ligation of
the left portal vein will depend on
Inferior vena cava
whether the caudate lobe is to be
resected with the specimen or left with
the remnant liver.
Injury to the Arterial Supply of
the Biliary System
Consequence
Injury to the right hepatic artery, or its branches that
supply the major bile ducts, can result in ischemic
injury to the duct and subsequently long-term bile duct
stenosis. Such stenosis can subsequently lead to recur-
rent episodes of cholangiitis or even the development
of cirrhosis of the remnant liver.
Grade 3 complication
Repair
Accidental division of the major bile duct that is to
drain the remnant liver after trisectionectomy requires
intraoperative reestablishment of biliary continuity.
This can be accomplished either through a direct end-
to-end anastomosis of the proximal duct and distal
common bile duct or by Roux-en-Y hepaticojejunos-
tomy. Although primary anastomosis can be considered
for dilated ducts, a bilioenteric anastomosis is usually
preferred for ducts that are of normal caliber because
the risk of postoperative biliary stenosis is minimized.
In cases of unrecognized biliary injury due to ischemic
damage to the major bile duct draining remnant liver,
repair involves reoperation and Roux-en-Y hepaticojeju-
nostomy. If the patient presents with postoperative cho-
langiitis due to biliary obstruction, the percutaneous
transhepatic drainage of the remnant biliary system should
be performed prior to denitive repair.
Prevention
Knowledge of the arterial blood supply to the extrahe-
patic biliary system is important in order to avoid isch-
33 TRISECTIONECTOMY 349
Left superior, inferior
hepatic ducts
Hepatic portal vein
Abdominal aorta
Common hepatic artery
emic insult to the biliary drainage of the remnant liver
after trisectionectomy. The epicholedochal plexus at
the biliary bifurcation derives its blood supply primarily
from the right hepatic artery, which sends a branch to
the plexus when it passes posterior to the common bile
duct. Therefore, dissection and division of the right
hepatic artery during right trisectionectomy should be
performed to the right of the common bile duct in
order to avoid damaging this branch.21 Furthermore,
division of biliary structures during major hepatectomy
should be delayed until after parenchymal resection in
order to avoid biliary injury. Minimization of hilar dis-
section is also preferable in order to avoid injury to the
vascular supply of the remnant biliary duct. Recently
described techniques in which the glissonian sheaths of
the segments to be resected are isolated and divided
individually can help limit the degree of hilar dissection
necessary to achieve resection.22
In cases in which extrahepatic bile duct excision is
necessary, especially when the indication for resection is
a perihilar cholangiocarcinoma, the common bile duct
should be excised extrahepatically as close to the pancreas
as possible in order to ensure negative resection margins.
After the bile duct has been resected, the sectional bile
duct draining the remnant liver can then usually be recon-
structed using a Roux-en-Y hepaticojejunostomy.
Control of Outow Vessels
Massive Hemorrhage due to Injury to
the Hepatic Vein or the IVC
The best way to prevent massive, life-threatening hemor-
rhage during major hepatic resection is to establish ade-
 350 SECTION IV: HEPATOBILIARY SURGERY
quate control of vascular inow and outow prior to
dissection of juxtacaval adhesions or tumor.
Consequence
Massive hemorrhage due to vena caval or hepatic
venous injury is the primary cause of intraoperative
mortality during hepatectomy.
Grade 5 complication
Repair
If bleeding results from a tear of a hepatic vein at its
junction with the liver, then the vessel loops or umbil-
ical tape previously placed around the hepatic veins and
the hepatoduodenal ligament should be tightened so
as to prevent blood ow into and out of the liver. The
venous injury can then be repaired primarily. If bleed-
ing arises from the IVC, then rapid control proximal
and distal to the site of injury may be required. Control
of the infrahepatic cava can be achieved rather quickly
using direct pressure. Control of the suprahepatic cava
may be more difcult. If access to this area is obscured
by the liver or by tumor, the patients incision can be
extended at the midline into a median sternotomy in
order to obtain rapid control of the supradiaphragmatic
vena cava. The vena caval injury can then be repaired
using either primary repair or venoplasty with the
greater saphenous vein.
Prevention
Adequate control of the vascular inow and outow of
the liver to permit total hepatic vascular isolation is
essential for prevention of massive hemorrhage during
major hepatectomy. This is especially true for trisectio-
nectomy, when complete mobilization of the liver is
required, and for tumors abutting the IVC or hepatic
veins. Control of hepatic inow is described later. The
technique needed to obtain proper control of the
hepatic veins requires division of the falciform ligament
in a cephalad direction to the upper peritoneal folds of
the right and left triangular ligaments.23 The gutter
between the liver, the right hepatic vein, and the middle
hepatic vein is then developed by blunt dissection from
an anterior approach. The right lobe is then fully mobi-
lized and retracted upward and medially. The numer-
ous short posterior tributaries between the vena cava
and the posterior right lobe or caudate lobe that are
invariably present must then be ligated and divided. If
a right inferior hepatic vein is also present, as is the case
for 20% of patients, it should also be ligated and divided,
unless it is large or a left trisectionectomy with preser-
vation of the right posterior segments is being per-
formed. After ligation and division of the hepatocaval
ligament, the right hepatic vein can then be safely
encircled with a tape. For extrahepatic control of the
middle and left hepatic veins, the peritoneal reection
above the caudate lobe is divided, followed by ligation
and division of the ligamentum venosum.24 The junc-
tion of the left hepatic vein and vena cava are thereby
exposed. A blunt dissector can then be passed into the
gutter between the right and the middle hepatic veins,
and the common trunk to the middle and left hepatic
veins thereby encircled with a tape.
Parenchymal Transection
Intraoperative Bleeding
Intraoperative blood loss is an inevitable part of major
hepatectomy. Massive hemorrhage owing to major hepatic
venous or caval injury is immediately life-threatening.
Steps to avoid this type of hemorrhage have been outlined
previously. Bleeding that occurs during hepatic parenchy-
mal transection may be more insidious, but the total
amount of blood lost during this part of the procedure
can be signicant. This is especially true during left trisec-
tionectomy, when the plane of transection is relatively
large compared with that in right trisectionectomy.
Consequence
Intraoperative bleeding requiring blood transfusion has
been frequently cited as a signicant predictor of pos-
thepatectomy morbidity.2,2427 Analysis of trisectionec-
tomy patients reinforces this relationship. In a review
of 70 patients undergoing left hepatic trisectionectomy,
Nishio and colleagues3 identied intraoperative blood
transfusion as an independent risk factor for postop-
erative morbidity. The mechanism underlying this rela-
tionship between intraoperative blood loss and increased
postoperative morbidity is likely multifactorial. For
example, the immunosuppressive effects of transfused
blood products have been shown to increase the inci-
dence of postoperative infectious complications after
hepatectomy.27,28 In addition, the nding that periop-
erative blood transfusion is an independent risk factor
for recurrence of hepatocellular carcinoma status after
hepatectomy suggests that the immunosuppressive
effects of blood products may have adverse oncologic
consequences as well.29
Grade 5 complication
Repair
Unlike hepatic venous or caval injuries, for which repair
of the injury will stop the bleeding, no specic repair
exists for hemorrhage that occurs during parenchymal
transection. Instead, efforts should be focused on pre-
venting such bleeding through meticulous transection
technique combined with judicious use of vascular
inow and potentially outow occlusion. When bleed-
ing does occur and is not associated with hemodynamic
instability, avoidance of routine blood product transfu-
sion is probably desirable. Ancillary management
options to help limit the need for blood transfusion
include preoperative autologous blood donation, the
use of erythropoietic stimulants, selective transfusion
criteria, and isovolumic hemodilution. The best way to

avoid the need for blood transfusion, however, is to
prevent excessive blood loss intraoperatively.
Prevention
Techniques for prevention of blood loss during paren-
chymal transection, and thus the need for perioperative
blood transfusions, have focused on the use of vascular
inow and outow occlusion and on techniques for
parenchymal transection. The simplest method for lim-
iting blood loss by vascular inow occlusion is to clamp
the main hepatic pedicle, a technique popularly known
as the Pringle maneuver.30 To perform this maneuver,
the hepatoduodenal ligament is dissected free of sur-
rounding adhesions and encircled with tape. The liga-
ment is then compressed using either a Rommel
tourniquet or a vascular clamp while the parenchymal
transection is being performed, with complete occlu-
sion of the pedicle being conrmed by absence of the
hepatic arterial pulse. The hemodynamic changes asso-
ciated with hepatic pedicle clamping are mild and
usually very well tolerated.31 The duration of inow
occlusion that the remnant hepatic parenchyma will
tolerate depends on whether the clamp is applied con-
tinuously or intermittently. Continuous clamping will
be tolerated for up to 60 minutes by a normal liver but
for less than 30 minutes in a steatotic or cirrhotic
liver.31,32 Continuous clamp times beyond these will
considerably increase the risk for postoperative hepatic
insufciency. If intermittent clamping is used, in which
clamped periods of 15 to 20 minutes are alternated
with unclamped periods of 5 minutes, the duration of
ischemia tolerated by a normal liver can be increased
to up to 120 minutes.33 The reason for the increased
tolerance of hepatic parenchyma to intermittent rather
than continuous hepatic pedicle clamping likely involves
a favorable preconditioning of hepatic parenchyma to
ischemia reperfusion provided by the intermittent
clamping method.34 Because of this hepatoprotective
effect, the greater extent of splanchnic congestion that
occurs with continuous clamping, and the prospective
observation that continuous clamping does not result
in less total operative blood loss compared with inter-
mittent clamping, intermittent hepatic pedicle clamp-
ing appears to be the preferred mode of hepatic
vascular inow interruption.35
Alternatives to occlusion of the entire hepatic vascular
inow include hemihepatic clamping or segmental vascu-
lar clamping.24 These techniques involve the selective
interruption of hepatic arterial and portal venous inow
of the hepatic segments to be resected, without interrup-
tion of inow to the remnant liver. The theoretical advan-
tages of these selective inow occlusion techniques are
that they avoid ischemic insult to the remnant liver,
demarcate the area of liver that is to be resected, and limit
the negative effects of hepatic pedicle clamping on splanch-
nic circulation and overall hemodynamics.36 Disadvantages
to selective vascular inow occlusion include the signi-
33 TRISECTIONECTOMY 351
cant hilar dissection required for selective clamping and
the potential for bleeding from the transected edge of the
nonoccluded liver. Because of these disadvantages, the
selective technique appears to be most useful in cases in
which a clear demarcation of the segment to be resected
is desirable, such as in patients with cirrhosis in whom it
is important to limit the degree of resection.31
There are several reasons why hepatic pedicle clamping
may fail to adequately suppress blood loss during paren-
chymal transection: (1) incomplete clamping of the hepatic
pedicle, (2) unrecognized replaced or accessory left hepatic
artery, (3) the existence of hypervascular adhesions, which
can occur in patients who have undergone prior hepatic
resection or preoperative arterial chemoembolization, and
(4) signicant backow bleeding from the hepatic venous
system. If the rst three possibilities have been ruled out
and bleeding remains signicant, consideration can be
given to minimizing hepatic venous ow. The simplest
and easiest way to minimize hepatic venous ow is to
reduce the central venous pressure, which constitutes the
driving force for hepatic venous backbleeding, to less than
5 cm H2O.37 This can usually be achieved by careful
volume restriction, but it requires an anesthesiology team
specically trained in this technique. The combination of
intermittent hepatic pedicle occlusion and low central
venous pressure anesthesia appears to result in a signicant
reduction in intraoperative blood loss and may, therefore,
contribute to a reduction in postoperative morbidity and
mortality.38 Patients with heart failure or pulmonary arte-
rial hypertension may be refractory to attempts to lower
central venous pressure. In these situations, caval or
hepatic venous occlusion may be necessary in addition to
inow occlusion.
Total hepatic venous exclusion (THVE) involves placing
clamps on the infrahepatic and suprahepatic IVC. This
technique requires complete mobilization of the liver
from its ligamentous attachments and adhesions. The
right adrenal vein may require division in order to com-
pletely mobilize the infrahepatic cava. Once exposure to
the cava is completed, clamps are applied to the hepato-
duodenal ligament, the infrahepatic cava, and the supra-
hepatic cava, in that order. Maximal tolerable clamping
durations, either for continuous clamping or for intermit-
tent clamping, are similar to those tolerated during hepatic
pedicle clamping alone. Once the parenchymal transection
is complete, the clamp on the infrarenal vena cava is par-
tially released in order to release any trapped air, and the
clamps are removed in the reverse of the order in which
they were originally placed.31
The major disadvantage to THVE is the effects that
complete interruption of inferior vena caval ow have
on the cardiovascular system and splanchnic circulation.
Owing to loss of preload by up to 60%, cardiac output
will decrease signicantly. Reexive increases in the heart
rate and systemic vascular resistance by up to 80% will
usually limit the resulting decrease in mean arterial pres-
sure to only 10% to 12%, with the cardiac index being
 352 SECTION IV: HEPATOBILIARY SURGERY
reduced by up to 50%.24 In approximately 10% to 15% of
patients, however, the necessary sympathetic reex does
not occur, and as a result, the cardiac output will drop by
more than 50% and the mean arterial pressure by more
than 30%.35 It is difcult to determine preoperatively
which patients will not tolerate THVE, but an initial 2- to
5-minute trial of total vascular exclusion is generally pre-
dictive of a patients hemodynamic tolerance of this
technique. Other potential deleterious effects of THVE
include renal compromise, splanchnic congestions, and
hyperamylasemia.24 In addition, patients who have under-
gone preoperative arterial chemoembolization may have
dense adhesions between the vena cava and the caudate
lobe and may risk signicant injury to the caudate or cava
during placement of the infrahepatic clamp. Therefore, it
is generally recommended that THVE be avoided in cir-
rhotic patients, patients with preexisting renal dysfunc-
tion, or patients who have undergone preoperative arterial
chemoembolization.35 In these patients, and in those who
do tolerate THVE hemodynamically, selective hepatic
venous exclusion can be attempted in order to limit venous
backbleeding during parenchymal transection.
Selective hepatic venous exclusion (SHVE) involves the
isolation and extrahepatic control of the right hepatic vein
and the common trunk of the middle and left hepatic
veins. The techniques required to isolate the hepatic veins
have already been described. Because vena caval ow is
not interrupted, the hemodynamic effects of SHVE are
similar to those seen with hepatic pedicle clamping and,
thus, are generally well tolerated.31 Persistent venous
backbleeding despite SHVE generally implies that a major
venous tributary, from either an inferior right hepatic vein
into the posterior right lobe, a short tributary from the
cava to the posterior right lobe or the caudate lobe, or a
left phrenic vein into the left hepatic vein, has not been
properly identied. Whereas SHVE may be more techni-
cally challenging than THVE, it offers clear advantages in
terms of hemodynamic stability and sparing of deleterious
renal or splanchnic effects. Therefore, it should be con-
sidered the preferred technique for achieving hepatic vas-
cular outow occlusion when needed to limit venous
backbleeding during parenchymal transection.35 The pres-
ence of tumor at the cavohepatic junction may make the
dissection required for SHVE too dangerous, however, in
which cases, THVE or potentially even venovenous bypass
will be required.
Other approaches toward minimizing blood loss and
the need for transfusion during major hepatic resections
such as trisectionectomies have focused on the technique
used for parenchymal transection. The traditional method
for dividing hepatic parenchyma involved crushing the
parenchyma with either a pair of clamps or the thumb and
forenger and then ligating and dividing the bile ducts
and vessels isolated in this manner. More recently, several
devices have been developed in an attempt to limit the
blood loss associated with parenchymal transection and
potentially to limit the duration of hepatic vascular inow
occlusion that is needed during transection.39 One such
device is the ultrasonic dissector (Cavitron ultrasonic
surgical aspirator, Tyco Healthcare, Manseld, MA),
which uses ultrasonic energy to locate ducts and vessels,
thereby facilitating their identication prior to ligation
and division. Another device is the Hydrojet (Erbe,
Tbingen, Germany), which uses a pressurized water jet
to dissect the hepatic parenchyma, thus exposing vessels
for ligation and division. The dissecting sealer (TissueLink,
Dover, NH) device, meanwhile, combines radiofrequency
and saline in order to precoagulate hepatic parenchyma
prior to ligation and division of vessels. Only a few ran-
domized, prospective trials have been performed to
compare these various techniques of parenchymal transec-
tion. The traditional clamp-crushing technique was com-
pared with an ultrasonic dissector in one study of 132
patients undergoing partial hepatectomies.40 The ultra-
sonic dissector did not result in any signicant improve-
ment in blood loss, transection time, or transection speed,
but it did cause more frequent tumor exposure at the
surgical margin. Another prospective, randomized trial
compared the ultrasonic dissector with a water-jet dissec-
tor and found that the water-jet dissector resulted in
signicant reductions in transection time, transfusion
requirements, and duration of hepatic pedicle occlusion
required.41
In a more recent trial, 100 consecutive patients under-
going liver resection were randomized to one of four
different transection strategies: (1) the traditional clamp-
crushing technique with routine inow occlusion, (2)
ultrasonic dissection without inow occlusion, (3) water-
jet dissection without inow occlusion, and (4) saline-
linked dissecting sealer without inow occlusion.39 The
authors found that patients who underwent transection
using the clamp-crush technique had the quickest transec-
tion times and lowest blood loss of the four different
techniques. Furthermore, the clamp-crush technique was
shown to be the least costly, and the number of surgical
clips or sutures required during parenchymal transection
was no greater with the clamp-crush technique than with
the other three techniques. These results suggest that
parenchymal transection using the traditional clamp-crush
technique may be more cost effective than using the
newer devices. Ultimately, the choice of which transection
technique to use seems to depend mostly on surgeon
preference.
Postoperative Biliary Leak
Postoperative bile leakage occurs in approximately 3% to
12% of patients undergoing hepatectomy, with the inci-
dence being highest in those patients undergoing the
most extensive resections.42,43 There are several potential
mechanisms for this complication. Biliary leakage from
smaller, peripheral biliary ductules can occur postopera-
tively from the cut surface of the hepatic parenchyma,
either because such leaking ductules are not ligated suf-
ciently intraoperatively or because the cut surface of the

liver necroses and sloughs off, thus exposing these duct-
ules. Leaks from major bile ducts can occur owing to
intraoperative injury, inadequate ligation, or ischemia of
the ligated stump with resulting necrosis and bile leakage.
Other potential mechanisms for postoperative biliary
leakage include leakage from bilioenteric anastomoses
(when bile duct excision is required for complete resection
of hilar cholangiocarcinoma), or leakage from immature
T-tube sites. Of these potential mechanisms, leakage from
peripheral ductules on the cut surface of the liver appears
to be the most common culprit.
Consequence
The consequences of posthepatectomy biliary leakage
stem from the presence of bile in the peritoneal cavity.
Postoperative biliary leaks can cause exacerbation of
abdominal pain, as well as other nonspecic gastrointes-
tinal symptoms such as ileus. Postoperative bile collec-
tions can lead to intra-abdominal sepsis as well. Because
patients undergoing trisectionectomy have little hepatic
reserve immediately postoperatively, the development
of such infection can lead to excessive metabolic demands
on the hepatic remnant and, thus, the development of
postoperative hepatic failure.44 For this reason, postop-
erative biliary leakage has been associated with an
increased risk of postoperative liver failure and death,
as well as prolonged hospitalization.43
Grade 3 complication
Repair
The traditional management of postoperative biliary
leakage often involved reoperation in order to identify
and repair the site of leakage and to ensure adequate
external drainage of the leaking bile. However, reop-
eration for bile leakage is associated with a signicant
increase in mortality rates, especially in patients with
marginal posthepatectomy hepatic reserve owing to
extensive resection. One retrospective review of patients
with biliary leakage after hepatectomy found that the
mortality rate of patients requiring reoperation owing
to major bile leakage was almost 80%.43 Other studies
support the extremely challenging nature of reopera-
tions for biliary leakage.45 With the increasing avail-
ability of nonoperative management options for this
complication, reoperation should therefore be reserved
for patients with leaks from major bile ducts, those with
life-threatening sepsis, and those in whom nonopera-
tive management has failed to control or resolve the
biliary leak.
There are two primary considerations in managing
patients with posthepatectomy leaks. First, appropriate
control of leaking bile is necessary in order to prevent the
development of intra-abdominal sepsis and, potentially,
liver failure and death. Therefore, a patient with signs of
infection that may be due to bile leakage should undergo
ultrasound or computed tomography in order to assess
for uid collections. Percutaneous drainage of such col-
33 TRISECTIONECTOMY 353
lections can then be performed as needed, with the uid
returned being sent for bilirubin levels and bacterial
culture. Broad-spectrum antibiotics should be started
until culture and antibiotic sensitivity data from the drain-
age uid are available. If such measures result in adequate
drainage of the bile leak and control of intra-abdominal
infection, the patient can be managed expectantly. Drains
can eventually be removed if the volume of output reduces
to zero and the patient remains clinically well.
In patients with persistent or high volumes of bilious
drainage, efforts to determine the site of biliary leakage
are warranted. Endoscopic retrograde cholangiopancrea-
tography (ERCP) is probably the preferred diagnostic test
in this case because it is minimally invasive and offers
the potential for simultaneous therapeutic intervention.
Patients with a major duct injury can then undergo tem-
porary covered stent placement over the injury site, with
a follow-up ERCP 4 to 6 weeks later to remove the stent
and assess duct integrity. Patients without extravasation of
contrast on initial ERCP can be assumed to be leaking
bile from the cut surface of the liver. In such cases, several
groups have shown that endoscopic sphincterotomy with
or without placement of a temporary stent across the
sphincter of Oddi may be helpful. These measures help to
reduce the intraluminal pressure within the biliary system
and, therefore, may facilitate healing of the leakage site.
Alternatively, a nasobiliary drain can be placed, although
this approach is less desirable from the standpoint of
patient comfort. Several groups have reported successful
management of persistent posthepatectomy biliary leaks
using ERCP and stent or nasobiliary drainage placement,
making this the preferred approach for patients with this
complication.42,46,47
Finally, some groups have advocated injecting ablative
substances such as ethanol or brin glue into the percu-
taneous drains of patients who develop persistent postop-
erative biliary leaks that show no communication of the
leakage point with the main biliary system on postopera-
tive cholangiography.45,47,48 Whereas this technique offers
the theoretical possibility of stula closure, and has met
with some anecdotal success, there are no published
studies comparing this technique to other methods of
biliary stula management.
Prevention
In patients in whom a left trisectionectomy is planned,
preoperative cholangiography is suggested in order to
delineate potential biliary anatomic variations. In some
patients, biliary ducts from the caudate lobe or right
posterior segment will drain into the left hepatic duct
close to the hilum. These patients are, therefore, at
higher risk for postoperative biliary leakage during left
trisectionectomy because the left hepatic duct will
require division close to the hilum. Knowledge of any
existing anatomic variants in these patients will there-
fore help to minimize the risk of postoperative biliary
leakage.43
 354 SECTION IV: HEPATOBILIARY SURGERY
Regarding biliary leakage from the cut surface of the
liver, three major intraoperative techniques to detect
potential leakage points have been developed: intraopera-
tive cholangiography, bile leakage testing using methylene
blue or normal saline, and application of brin glue to the
cut surface of the liver. Injection of diluted methylene
blue or isotonic normal saline into the cystic duct after
parenchymal transection can reveal leaking peripheral
biliary ductules at the cut surface. These ductules can then
be individually ligated. Alternatively, an intraoperative
cholangiogram can be performed if the integrity of major
bile ducts is in question. In a retrospective review of the
usefulness of these detection techniques in 616 patients
undergoing hepatic resection, Lam and coworkers49 found
that the postresection methylene blue test resulted in a
signicant reduction in postoperative biliary leak rates,
whereas intraoperative cholangiography did not signi-
cantly lower leak rates. In this same study, however, 10%
of patients in whom the methylene blue test failed to
demonstrate leak still developed biliary leaks postopera-
tively, indicating that this leak detection method is not
always successful. Furthermore, a prospective study by
Ijichi and associates50 randomized patients undergoing
hepatic resection to receiving or not receiving a biliary
leakage test intraoperatively. This study failed to show any
signicant benecial effect of intraoperative leakage testing
on the development of postoperative biliary leaks. Other
authors have echoed the belief that intraoperative leakage
tests are not signicantly effective in preventing postop-
erative biliary leaks, potentially because the segment of
liver at which the leak originates may no longer be in
continuity with the main biliary system.43 Based on the
available literature, therefore, routine intraoperative bile
leak testing cannot be recommended.
Substances such as brin glue have also been applied to
the cut surface of the liver intraoperatively to prevent the
development of postoperative biliary leakage.51 A recent
prospective, randomized trial showed that patients who
had brin glue applied to the cut surface of their liver
postresection had signicant reductions in postoperative
drainage volumes compared with patients who did not
receive brin glue application.52 There was no analysis of
drain content in these patients, however, and thus the
incidence of postoperative biliary leakage in the two
groups of patients was not known. Only one other pro-
spective, randomized trial of topical sealants has been
performed.53 In this trial, patients undergoing hepatic
resection were randomized to either microcrystalline col-
lagen powder or brin glue applied topically to the cut
surface of the liver. Despite the absence of a control
population of patients in this study, patients in both the
collagen powder and the brin glue groups had a 6% rate
of postoperative biliary leakage. Other groups have retro-
spectively analyzed the use of brin glue application and
have found that it does not reduce the incidence of post-
operative biliary leakage.49 Therefore, routine use of brin
glue to the cut surface of the liver cannot be recom-
mended as a reliable method for preventing postoperative
biliary leakage.
In summary, the development of postoperative biliary
leakage is a common complication among patients under-
going major hepatectomy. No intraoperative technique
has yet been developed that fully prevents this complica-
tion. Intraoperative cholangiograpy may help to detect
injury to major bile ducts if there is some reason to suspect
such injury, and injection of saline or methylene blue into
the cystic duct after cholecystectomy may help to ident-
ify potential sites of leakage from the postresection cut
surface, but neither of these detection methods nor the
topical application of brin glue has been found to reliably
prevent postoperative bile leaks from occurring. Necrosis
of the cut surface, possibly in combination with intra-
abdominal infection, may help to explain why such man-
euvers do not prevent postoperative biliary leakage.
Meticulous surgical technique, therefore, remains the
primary method for minimizing the development of this
complication.
Other Complications
Postoperative Hepatic Insufciency
Postoperative hepatic insufciency is a dreaded complica-
tion of hepatic resection. The incidence of postoperative
hepatic failure varies from institution to institution and
depends in part on the dening parameters. In a retrospec-
tive analysis of over 1000 patients undergoing hepatec-
tomy at one center, Imamura and colleagues54 reported
only 1 patient who developed hepatic failure postopera-
tively. This group dened hepatic failure as a bilirubin
level greater than 5.0 mg/dl and/or a prothrombin rate
of less than 50% for 3 or more consecutive days. Because
trisectionectomy involves resection of up to 80% of
functioning liver parenchyma, it is expected that this pro-
cedure would be associated with higher rates of postop-
erative hepatic failure than those of lesser resections.
Indeed, Nagino and coworkers55 reviewed the postopera-
tive complications in 105 patients who underwent hepa-
tectomy for hilar cholangiocarcinoma. This group found
that postoperative hepatic failure developed in 16.7% of
patients who had less than 50% of their liver resected
versus 36.8% of patients who had resection of greater than
50%. In an analysis of 70 patients undergoing left trisec-
tionectomy, 17% of patients developed transient hepatic
insufciency postoperatively.3 Other reports cite a 3% inci-
dence of this complication after 51 extended left hepatec-
tomies and a 6.7% incidence in 33 patients undergoing
right trisectionectomy.5,56
Consequence
The sequelae of this complication depend on the extent
of organ insufciency that develops. In general, the
metabolic and reticuloendothelial functions of the liver
will be impaired, resulting in decreased protein synthe-
sis and compromised host-defense functions. As a

consequence, patients with postoperative hepatic insuf-
ciency become more prone to malnutrition, infectious
complications, and impaired healing of incisions and
anastomoses. These patients are also more prone to
respiratory and/or renal failure, with the stress of sys-
temic infection or other organ failure further compro-
mising the already failing liver. The mortality rate
associated with isolated postoperative liver failure is
6.1%, although this increases to up to 33% when
patients with concomitant failure of other organs are
included.1,55
Grade 4 complication
Repair
Management of mild or moderate postoperative hepatic
insufciency is generally supportive, with the duration
of insufciency usually correlating with the amount of
time required for adequate functional hepatic regen-
eration to occur (typically about 3 wk).57 In cases of
severe, life-threatening postoperative liver failure,
hepatic transplantation may be a viable therapeutic
option, depending on the indication for resection.
Prevention
Two general measures can be taken to prevent the
development of hepatic insufciency after major hepatic
resection. Postoperatively, it is important to avoid con-
ditions that place excessive stress on the metabolic
functions of the liver. Thus, the avoidance of gastroin-
testinal hemorrhage, systemic infection, or renal failure
will help to prevent pushing a patient with borderline
hepatic function into catastrophic liver failure.
Because the risk of developing postoperative hepatic
dysfunction is directly related to the amount of functional
hepatic tissue that is resected, a considerable amount of
research has been directed toward determining preopera-
tively the amount of liver tissue that can be safely resected
in a given patient. This ability of individual patients to
tolerate major hepatic resections such as trisectionectomy
depends both on the extent of resection needed to achieve
oncologic benet (assuming the resection is for malig-
nancy) and on the quality of the remnant hepatic tissue.
Generally, a patient with normal hepatic function preop-
eratively and no evidence of cirrhosis or chronic hepatitis
can tolerate removal of as much as 75% to 80% of their
total hepatic volume. Patients with compromised hepatic
function due to steatosis, cirrhosis, or hepatitis, however,
may not be able to tolerate this much resection.
Several techniques have been developed that attempt to
predict postoperative residual liver function in these
patients with preoperative cirrhosis.58 Indocyanine green
(ICG), for example, is taken up by the hepatocytes after
intravenous injection and excreted into the bile unchanged.
Serial measurement of ICG levels at 5-minute intervals
after its injection can help to detect the clearance rate of
this substance by the liver, which is generally greater than
90% after 15 minutes.59 Patients with cirrhosis and ICG
33 TRISECTIONECTOMY 355
retention greater than 14% after 15 minutes have been
found by some groups to have increased risk of postop-
erative mortality after liver resection.59,60 Several groups
have successfully incorporated ICG clearance rates into
their preoperative assessment of patients with cirrhosis
in order to plan the extent of hepatic resection in these
patients, a strategy that has resulted in favorable mortality
rates.54,61 ICG clearance rates should generally not be
used as the sole determinant of the extent of resection to
undertake, or of whether or not to perform resection in
the rst case, because the test is not completely accurate
as a predictor of postoperative hepatic dysfunction.58
Another test of preoperative hepatocyte function is the
monoethylglycinexylidide (MEGX) test, which assesses
the ability of the hepatic cytochrome P-450 pathways
to convert lidocaine to monoethylglycinexylidide. Low
venous concentrations of MEGX 15 minutes after injec-
tion of lidocaine have been shown to correlate both with
the degree of cirrhosis and with the risk of hepatic dys-
function after hepatectomy.62 This test has been shown to
compare favorably with ICG clearance testing as a measure
of liver function, although both tests are somewhat limited
by their dependence on hepatic blood ow.63 Several
other methods for determining the extent of hepatocyte
dysfunction have also been developed, including the hip-
purate ratio, the aminopyrine breath test, the amino acid
clearance test, the caffeine clearance test, galactose elimi-
nation capacity, and the arterial ketone body ratio. These
methods have variable prognostic efcacy compared with
that of ICG and MEGX in predicting which cirrhotic
patients who undergo liver resection will develop postop-
erative hepatic failure and death.58
Another potentially useful method for determining a
patients risk for developing hepatic dysfunction after liver
resection is to estimate the anticipated volume of hepatic
tissue that will remain with the patient after resection
(i.e., the remnant liver volume). Such estimations are
achieved by volumetric analysis using computed tomog-
raphy and have been shown to correlate well with the
amount of hepatic tissue actually resected.58 Furthermore,
the ratio of the anticipated remnant liver volume to
total liver volume has been shown to correlate well with
a patients risk of postoperative hepatic dysfunction.
In an analysis of 126 patients undergoing liver resec-
tion for colorectal metastases, the group at Memorial
Sloan-Kettering found that 90% of patients with a remnant
liver volume of less than 25% based on preoperative volu-
metric analysis developed postoperative hepatic dysfunc-
tion, compared with none of the patients undergoing
trisectionectomy who had a remnant liver volume greater
than 25%.64
The clinical utility of preoperative hepatic function
testing and volumetric analysis will depend on how this
information is used. Not only will the data obtained from
these studies help in estimating the maximum extent of
resection that can be tolerated by the patient, the informa-
tion derived from these tests may also assist in determining
 356 SECTION IV: HEPATOBILIARY SURGERY
whether the patient might benet from preoperative portal
vein embolization. The use of preoperative portal vein
embolization was rst reported in 1990 as a potential
method for promoting compensatory hypertrophy in the
future remnant liver of cirrhotic patients who require
major hepatic resection for malignancy.65 The ideal can-
didates for portal vein embolization are those patients
requiring extensive resection but who have only border-
line hepatic function (corresponding to an ICG clearance
value of 10%20% at 15 min).66 This technique does not
appear to be as useful for patients with hepatic tumors and
more severe liver dysfunction (ICG retention > 20%)
because the amount of time required for adequate com-
pensatory hypertrophy of the anticipated remnant liver
would be excessive in light of the relative urgency of pro-
ceeding from an oncologic perspective.
The use of portal venous embolization combined with
preoperative biliary drainage in patients with obstructive
jaundice has been shown to expand the surgical options
for patients needing extensive hepatic resection. In a ret-
rospective study of 79 patients undergoing major hepatic
resection for hilar cholangiocarcinoma, preoperative biliary
drainage was performed in 65 patients who had obstruc-
tive jaundice and in 41 of 51 patients undergoing extended
right hepatectomy. The in-hospital mortality rate for the
patients in this series was only 1.3%, and the incidence of
postoperative hepatic failure was zero.67 The combination
of portal venous embolization and preoperative biliary
drainage for patients with obstructive jaundice has enabled
the safe performance of trisectionectomy with minimal
postoperative mortality and hepatic failure in other recent
series as well and should, therefore, be considered in any
patient needing major hepatic resection who has preop-
erative evidence of obstructive jaundice and borderline
hepatic function.6
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34
Laparoscopic Liver Resection
Amit D. Tevar, MD, Mark J. Thomas, MD,
and Joseph F. Buell, MD

INTRODUCTION indications that would be considered for liver resection

include
The rapid evolution of technology and experience with Hemangioma
laparoscopic surgery has led to the feasibility of safe mini- Severe symptoms
mally invasive hepatic resection. The rst laparoscopic Hemorrhage
liver resection was reported by Gagner and coworkers in Focal nodular hyperplasia
1992.1 Ferzli and colleagues2 subsequently reported an Severe symptoms
additional hepatic resection in 1995. Azagra and associ- Growth on serial imaging
ates3 were the rst to perform a segmental resection, Uncertain diagnosis
describing a left lateral segmentectomy in 1996. Since Liver cell adenoma
these initial reports, multiple institutional series and a Simple liver cysts
few multicenter groups have reported segmental and Severe symptoms
nonsegmental resection for benign and malignant
The most common malignant lesions that would be
disease.424
considered for liver section include
The application of laparoscopic techniques for liver
resection has demonstrated equivalent morbidity and Hepatocellular carcinoma
mortality rates to those of open techniques. In addition, Noncirrhotic patients
the laparoscopic approach has resulted in decreased blood Childs A cirrhotic patients with lesion smaller than
loss, shorter postoperative stay, and reduced postoperative 5 cm
analgesic requirement for pain.18,25,26 Metastatic colon adenocarcinoma
Although technologic advancement and surgeon expe- Metastatic lesions noncolonic
rience have rapidly advanced the extent and safety of Include gastrointestinal stromal tumor (GIST),
laparoscopic liver resection, concern remains regarding melanoma, renal cell carcinoma, and others, only if
the oncologic integrity of laparoscopic resection for malig- no extrahepatic metastatic lesions and primary has
nant disease and of multiple potential complications. been controlled
These complications include those that are possible
with any liver resectionincluding functional synthetic
reserve in a cirrhotic liver, tumor recurrence, bleeding, OPERATIVE STEPS
biliary leakand those that are unique to laparoscopic
liver resection, such as CO2 embolism and port site Step 1 Patient positioning
metastasis. Step 2 Port placement
Step 3 Liver mobilization
Step 4 Laparoscopic intraoperative hepatic ultrasound
INDICATIONS Step 5 Parenchymal division
Step 6 Closure
The indications for laparoscopic liver resection are similar
to those for open procedure in regard to patient and lesion
characteristics. No liver resection should be performed
OPERATIVE PROCEDURE
using a laparoscopic technique that would not be indi-
cated using an open technique. Special consideration
Patient Positioning
should be given to preoperative imaging and the proxim-
ity of the lesions with the hepatic vein conuence and the Patient positioning is paramount to a successful laparo-
portal bifurcation. The most common benign lesions and scopic liver resection. Left lateral, left median segment,
 360 SECTION IV: HEPATOBILIARY SURGERY
12 mm
5 mm
lap disk 12 mm
Surgeon First assistant
Figure 341 Surgeon, laparoscopic and hand port placement for
left hepatic laparoscopic resection.
Figure 342 Operative table in full exion for decubitus posi-
tioning of patients for right sided laparoscopic liver resection.
and caudate lesions are best performed with the patient in
a supine position with the arms out6,7 (Fig. 341). This
allows for uncomplicated and safe division of the left tri-
angular and coronary, falciform, and gastrohepatic liga-
ments. Lesions involving the right lobe (segments 5, 6, 7,
and 8) are best laparoscopically approached with the
patient in a left decubitus position with the operative bed
in full exion (Fig. 342).
Port Placement
All laparoscopic liver resections at the University of Cin-
cinnati are performed with a hand-assist device (Lap-Disc;
Ethicon, Cincinnati, OH) in combination with low-prole
balloon ports. The hand-assist technique allows for tactile
feedback, which is an important tool in the armamentar-
ium for obtaining adequate margins in the malignant hepa-
tic resection (Fig. 343). The hand-assist also allows for
Figure 343 Laparoscopic hand port placement.
digital compression of parenchymal or vascular bleeding,
preventing unnecessary blood loss or CO2 air embolism.
As with any laparoscopic surgery, appropriate port and
surgeon placement greatly facilitates the operative tech-
nique, allowing for a safer and shorter case. The primary
surgeon leads the case by placement of his or her hand in
the hand port. In the case of left-sided lesions, the primary
surgeon resides on the patients right side in order to place
his or her right hand intracorporeally through a hand port
placed on the right to guide mobilization and parenchy-
mal division. Resection of the right lobe of the liver
involves the primary surgeon on the patients left side with
his or her assistant directly opposite. The primary sur-
geons left hand is placed through a right-sided hand port
to facilitate dissection, mobilization, and resection. Some
groups have placed the hand port in the midline with
success.
The low-prole balloon port is used, and the initial port
is placed using an open Hasson technique. In the cirrhotic
patient, the initial 12-mm balloon port is placed infraum-
bilically in order to avoid the large recannulized umbilical
vein circuit. If a varix is encountered, hemostasis should
be obtained with direct suture ligation. In the noncir-
rhotic patient, the initial port is placed supraumbilically,
again using an open technique. The remaining ports are
placed under direct visualization after pneumoperitoneum
is obtained. Right-sided lesions require placement of two
additional subcostal 12-mm ports. These should be placed
under direct visualization, and great care should be taken
to avoid cephalad or caudal placement of these ports.
Working ports placed too high will result in difculty
opening the jaws of a laparoscopic vascular staple owing
to the proximity to the liver. Working ports placed too
low will lead to inability of instrument to reach the right
and middle hepatic veins. The hand port is placed in the
right upper quadrant, just above and lateral to the supra-
umbilical port. It is recommended that the hand port be
placed more cephalad for right-sided lesions to allow for
hand retraction of the liver for dissection of the hepatic
veins and the bare area. Left-sided lesions require two

12 mm
12 mm
lap disk
12 mm
First assistant Surgeon
Figure 344 Surgeon, laparoscopic and hand port placement for
right hepatic laparoscopic resection.
additional left subcostal ports, placed in a similar fashion.
Our group routinely places the hand port in the right side
for left-sided resections, and it may be placed more cau-
dally than for right-sided lesions (Fig. 344).
Trocar Insertion Hollow Viscus Injury
This is an unnecessary complication that deserves special
consideration because the patient population undergoing
laparoscopic liver resection has often undergone previous
surgery or may have end-stage liver disease. The standard
trocar insertion is described previously, and the initial port
should be placed using an open technique. See Section I,
Chapter 7, Laparoscopic Surgery.
Trocar Insertion Bleeding
The patient population undergoing laparoscopic liver
surgery often has end-stage liver failure with impressive
supercial periumbilical vein circuits originating from a
recannulized umbilical vein.
Consequence
Variceal bleeding can be somewhat problematic because
of the large-volume, low-pressure, and thin-walled
veins. In addition, the variceal veins will often retract
into the subcutaneous fat and, when working through
a small 12-mm port skin incision, a signicant volume
of blood may be lost before the vein is visualized.
Repair
Direct digital pressure should be applied to the area in
order to minimize a potentially large volume of blood
loss. Blind electrocautery into the area of the bleeding
is usually ineffective. Visualization is key in controlling
this bleeding. Retraction with Army-Navy retractors
or extension of the skin incision may facilitate this.
Identication and direct ligation of both ends of the
varix with suture is the appropriate way to treat this
bleeding.
34 LAPAROSCOPIC LIVER RESECTION 361
Prevention
All patients with end-stage liver disease should be iden-
tied preoperatively by laboratory values. Even with
normal liver function tests and coagulation studies and
no evidence of ascites or encephalopathy, all patients
should be carefully examined after general anesthesia is
obtained for evidence of a caput medusae. The pre-
sence of other physical examination ndings classically
seen in portal hypertension suggest that periumbilical
varices may have developed, even if they are not readily
visible on visual examination.
Port placement for patients with end-stage liver disease
should begin with an infraumbilical 12-mm port using an
open Hasson technique. This generally will avoid disrup-
tion of any periumbilical varices.
Liver Mobilization
Mobilization is performed in a manner similar to that of
the traditional open technique. The left lobe is mobilized
by having the primary surgeon retract the left lateral
segment in an inferior and posterior position. The
laparoscopic ultrasonic cutting and coagulation device
(Harmonic Scalpel; Ethicon Endo-Surgery, Inc.) is then
used to divide the coronary and triangular ligament. The
dissection is taken to circumferentially clear the left and
middle hepatic veins. Great care should be taken at this
time to avoid injury to the phrenic vein. Injury to this
should be managed with digital compression and clip or
ultrasonic ligation. The left lateral segment is now retracted
in an anterior fashion, and the gastrohepatic ligament is
divided with the ultrasonic shears. In case an accessory left
hepatic artery is encountered, it should be divided using
the ultrasonic shears or ligated with clips and divided.
After complete mobilization of the left lateral segment,
the caudate lobe can also be mobilized for resection. The
peritoneum overlying the inferior vena cava is rst divided
with the ultrasonic shears. The posterior aspect of the left
hepatic vein is then fully mobilized, followed by the supe-
rior aspect of the caudate lobe. Once the small caudate
veins are ligated and divided, the main caudate vein is
circumferentially dissected and can be taken with a reload-
able laparoscopic articulating vascular stapler (Endo GIA
Roticulator; Autosuture, Tyco, Norwalk, CT). Caudate
portal vein branches may also be taken if needed.
The right lobe is mobilized by retracting the lobe medi-
ally and caudally with the primary surgeons hand through
the hand port. Ligament attachments are then divided
with the ultrasonic shears (Fig. 345). A combination of
blunt and sharp dissection is used to fully mobilize the
right lobe to the right hepatic vein. The inferior vena cava
ligament may be divided to facilitate visualization of the
right hepatic vein. The right hepatic and middle hepatic
veins are circumferentially dissected. The lateral attach-
ments of the inferior vena cava are divided using the
ultrasonic shears. Small branches from the vena cava to
the liver may be taken with the laparoscopic vessel sealant
device (LigaSure Lap; Valleylab, Boulder, CO) or with
clip ligation and laparoscopic shear division.
 362 SECTION IV: HEPATOBILIARY SURGERY
Figure 345 Mobilization of lateral attachments of the right lobe
using a laparoscopic ultrasonic cutting device.
Pneumothorax
Mobilization of the right lobe often requires ultrasonic
dissection. This thermal heat can lead to a diaphragm
injury and a spontaneous pneumothorax. This is extremely
vexing when the working space becomes compromised
with the mobile diaphragm.
Consequence
Airway pressures suddenly rise while the working space
becomes inhibited. Each pulmonary excursion results
in a billowing of the diaphragm, making continued
operating difcult.
Repair
Repair can be performed through open operative con-
version or a laparoscopic approach. In our practice, we
have elected to utilize continuous suction during suture
repair of the diaphragm. First, the diaphragm injury is
identied. Either a gure-of-eight or an interrupted
suture repair is performed around the injury. This can
be done with a suture passer device or free-hand sutur-
ing with intracorporeal knot tying. Once this is repaired,
an endoscopic suction device is placed in the thoracic
cavity. Aspiration of the free air is accomplished, and a
forced inspiration is performed to minimize the free
space. At that juncture, the suture is secured and the
suction device removed.
Prevention
This is achieved though meticulous placement of the
ultrasonic device. Pass pointing and adjacent thermal
injuries can be avoided by either conservative or metic-
ulous placement of these devices.
Laparoscopic Intraoperative
Hepatic Ultrasound
The ultrasound examination remains a crucial aspect of
any liver operation, and surgeons performing laparoscopic
Figure 346 Laparoscopic liver ultrasound.
hepatectomy should be familiar with the equipment and
well versed in assessment of the obtained images. The
laparoscopic ultrasound probe (8666 probe; B-K Medical,
Denmark) is used to methodically evaluate all segments
of the liver, looking for additional lesions, boundaries of
known lesions, and the relationship with the vascular
anatomy (Fig. 346). If the patient is still a candidate for
resection, a 2-cm margin around the lesion is marked with
the argon beam coagulator.
Inadequate Intrusion
Laparoscopic hepatic resection is dependent on adequate
working space. When there is insufcient space to deploy
or articulate instrumentation, this operative procedure
becomes impossible.
Consequence
Inadequate working space incapacitates most forms of
technology that are critical to the performance of these
operations.
Repair
Unfortunately, there are few remedies for the lack of
intrusion. The most widespread or universally accepted
procedure is the technique of laprolift. In this scenario,
the abdominal wall is elevated by the technique of
laprolift.
Parenchymal Division
Our group has avoided routine employment of the Pringle
maneuver. If brisk bleeding is encountered, direct com-
pression of the porta with the primary surgeons hand can
be performed while a laparoscopic vascular clamp is put
into position.
Parenchymal transection begins with division of the
Glisson capsule using the ultrasound shears at a line
marked with the laparoscopic ultrasound (Figs. 347 and
348). The technique used by our group involves liberal
use of 60-mm-long, 2.5-mm staple loads. The staple load
 34 LAPAROSCOPIC LIVER RESECTION 363

Figure 347 Division of Glissons capsule along an argon beam Figure 348 Division of Glissons capsule using a laparoscopic
marking line using a laparoscopic ultrasonic cutting device. ultrasonic cutting device.

Figure 349 Hepatic parenchymal resection using a reticulating laparoscopic vascular staple.

is guided into position using the intracorporeal hand. The
thin blade is guided into the liver parenchyma and then
red. The staples ligate any hepatic vessels or bile ducts.
As the cutting blade distance is shorter that the staple
length, partial division of large vessels remains hemostatic
(Fig. 349). Alternative methods to parenchymal division
include a saline infusion, radiofrequency ablation device
(TissueLink oating ball; TissueLink, Dover, NH) (Fig.
3410), with selective stapling or clip placement of large
vascular or biliary structures.
 364 SECTION IV: HEPATOBILIARY SURGERY
Figure 3410 Hepatic parenchymal resection using a saline infu-
sion, radiofrequency ablation device.
Figure 3411 Cut surface hemostasis with an argon beam coag-
ulation device.
Upon completion of the resection, cut surface liver
parenchymal bleeding can be controlled by argon beam
coagulation of the cut surface (Fig. 3411). Bile leakage
or focused arterial bleeding is controlled with free-hand
suturing or clip application. A hemostatic matrix of col-
lagen and topical thrombin (Floseal; Baxter, Deereld, IL)
is then applied to the cut surface.
After hemostasis and absence of bile leak is appropri-
ately assessed, the specimen is removed through the hand
port. The port itself acts as a wound protector and pre-
vents tumor seeding of the wound.
Venous and Arterial Bleeding
Hepatic arterial or venous bleeding can become a signi-
cant problem in the conned space of a laparoscopic pro-
cedure. This results from disruption of the small or large
portal or hepatic veins resting in the liver parenchyma.
Intraparenchymal hepatic arterial bleeding is another
potential source of bleeding when the liver parenchyma is
divided. This may be further complicated by a baseline
coagulopathy of the cirrhotic patient.
Consequence
The resulting blood loss can be quite signicant and
result in hemodynamic compromise if not recognized
and treated effectively in a timely manner. If not con-
trolled quickly, this blood loss will invariably result in
conversion to an open procedure or reexploration for
continued bleeding.
Repair
Intraoperatively, all patients should have their coagu-
lopathies corrected with fresh frozen plasma, cryopre-
cipitate, and/or platelets before proceeding with
hepatic resection. Central venous pressure should be
continuously measured through a central venous line
and be kept below 6 mm Hg. Again, recognition is
paramount in successfully controlling the bleeding.
Our group does not perform a Pringle maneuver before
beginning parenchymal division, which allows for early
identication of bleeding. The rst maneuver in con-
trolling bleeding is direct compression with the primary
surgeons intra-abdominal hand. This keeps blood loss
to a minimum and prevents the possibility of CO2
embolism if large hepatic veins are divided. In addition,
it safely allows for the remainder of the hepatic resec-
tion to be completed so that the entire cut surface can
be visualized, greatly simplifying direct permanent
control of bleeding vessels. Laparoscopic suturing or
clip application in the crevice of a partially completed
resection is extremely difcult and does not allow for
direct visualization.
In almost all cases, direct pressure with the intra-
abdominal hand and a laparotomy sponge will maintain
hemostasis until the surgeons are ready to perform more
permanent hemostatic maneuvers. In the case of a cir-
rhotic liver in which direct compression of the liver does
not always adequately stop bleedings, the surgeons hand
can be used to compress the portal structures. Visible
venous or arterial vessels on the cut surface should be
permanently ligated with clip application, direct laparo-
scopic suture ligation, or a laparoscopic vascular stapler.
Avoid argon beam coagulation of large vessels because this
does not provide permanent hemostasis and can lead to
gas embolization.
After major vessels have been ligated, the cut surface
parenchyma may be cauterized with the argon beam coag-
ulator. We often spread a collagen and thrombin hemo-
static matrix over the cut surface before closing.
Prevention
Among the different techniques available for parenchy-
mal division, our group employs liberal use of 60-mm
length, 2.5-mm staple loads. The staple load is guided
into position using the intracorporeal hand. The thin
blade is guided into the liver parenchyma and then
red. The staples ligate any hepatic vessels or bile ducts.
This results in a very hemostatic cut surface. When
using the Tissuelink device, it is important to identify
vessels and staple or clip them directly to avoid bleed-

ing. Vigilant attention should also be given toward
correction of the patients coagulopathy and mainte-
nance of adequate body temperature and central venous
pressure throughout the procedure.
Bile Leak
Biliary leakage remains a signicant problem in major
open hepatic resection. Reports from recent series have
shown the rate of biliary complications to range from 3%
to 10%, with mortality from major leaks to be as high as
40% to 50%.27,28
Consequence
The cut surface of the liver with associated cut bile duct
is a signicant source of bile leak. Many leaks are small
and will resolve without intervention. Larger leaks can
result in abdominal pain, bile peritonitis, abscess, or
abdominal sepsis. The large symptomatic leaks can be
high as 40% to 50%.
Repair
Intraoperative recognition and repair of bile leaks is
paramount to avoiding postoperative complications.
This involves thorough investigation for bile leak on
the cut surface prior to closure. This can be done
through direct visualization with the laparoscope or by
placing a clean laparotomy sponge on the cut surface
and looking for bile staining. We do not perform
routine cholangiogram on open or laparoscopic liver
resections to search for bile leaks.
Once a bile leak is discovered, it is repaired in the same
fashion as that for open hepatic resection, with free-hand
suture ligation or clip application. Again, intraoperative
recognition and repair of bile leaks are important.
If leaks are discovered postoperatively, they should be
treated aggressively with early endoscopic retrograde chol-
angiography and stent placement. If uid collections are
not adequately resolved by operatively placed drains, com-
puted tomography scan should be obtained and interven-
tional radiology percutaneous drains should be placed.
Prevention
Meticulous attention and focused search and repair of
bile leaks intraoperatively will invariably result in fewer
biliary complications.
Closure
Particular attention should be given to closure of all port
incisions because early herniation is an unnecessary com-
plication in laparoscopy. Also, because patients with end-
stage liver disease may have large-volume ascites with
diminished healing capacity, attention should be given to
meticulous technique to avoid closure breakdown in this
subgroup of patients.
Our technique involves a 1-0 permanent suture two-
layer closure for the hand port incision. The 12-mm port
sites should be closed using the laparoscopic fascial closure
device or an open technique.
34 LAPAROSCOPIC LIVER RESECTION 365
Other Complications
Intraoperative Hypotension
Pneumoperitoneum often leads to unexpected hypoten-
sion, as a result of patient intravascular volume depletion
and subsequent susceptibility to pneumoperitoneal pres-
sures. In laparoscopic liver resection, the patient is often
placed in a reverse Trendelenburg position, which worsens
central venous return. Subsequently, the blood pressure is
extremely sensitive to patient positioning.
Consequence
Often transient but signicant and dramatic hypoten-
sion can occur. Associated with this hypotension is
bradycardia rather than the expected tachycardia
resulting from hypotension.
Repair
Hypotension and bradycardia are responsive to atro-
pine and/or uid resuscitation utilizing normal saline
or 5% albumin. In more extreme cases, immediate
release of the pneumoperitoneum or repositioning of
the patient until adequate central volume resuscitation
is achieved is required.
Prevention
Adequate resuscitation of the patient is critical. The
goal of central venous pressure is 6 to 8 mm Hg.
However, excessive volume depletion is inappropriate
and dangerous. Management of these patients with a
central venous line to monitor pressures is very helpful
in monitoring volume status.
Major Air Embolism
A potentially fatal complication of minimally invasive
hepatic resection is major air embolism. Signicant disrup-
tion of the hepatic venous system in the face of CO2
pneumoperitoneum may result in air embolism to the
central venous system. Subsequent air lock hypotension
and fatal arrhythmia may follow. This is the most feared
complication of hepatic transection performed under
positive pressure.
Consequence
Air embolism is a known complication of hepatic resec-
tion. This rare complication is the result of air entering
a vessel and becoming trapped within the atrium. The
most susceptible patients to fatal complications are
those with patent foramen ovale. This allows for
trapp-ing of air in the right ventricle outow tract,
resulting in air lock with resultant hypotension or even
cardiac arrest.
Repair
Procedure-related hypotension should be monitored
closely. In the event of a signicant drop in end-tidal
CO2 along with decreases in oxygen saturation and/or
hypotension, the pneumoperitoneum should be
 366 SECTION IV: HEPATOBILIARY SURGERY
released and the patient hand-ventilated. The most sen-
sitive test for air embolism remains transesophageal
echocardiography, which can detect less than 0.02 ml/
kg of air. Treatment should be instituted immediately
on suspicion of air embolism. The patient should imme-
diately be placed in a Trendelenburg and left lateral
decubitus position. Administration of 100% oxygen
should begin immediately because it may decrease
bubble size. Pulmonary artery or central venous cath-
eters should be advanced into the heart and aspirated,
in hopes of aspirating trapped air. In the case of circula-
tory collapse, advanced cardiac life support protocol
should be instituted with cardiopulmonary resuscita-
tion because this may break bubbles and advance air
into pulmonary vessels and out of the heart.
Prevention
Several authors have advocated the elimination of
pneumoperitoneum and the use of a laprolift.29,30
Others advocate use of low pneumoperitoneum. Several
air embolisms have been documented in the perfor-
mance of laparoscopic hepatic resection. One reported
fatality resulted from air embolism after an argon beam
use in the liver.31 Avoidance of direct gas instillation in
an open hepatic vein is critical to preventing this com-
plication. In our practice, the use of high pneumoperi-
toneal (1518 mm Hg) pressures is common. Another
consideration is avoidance of nitrous oxide anesthetic
because it will cause expansion of any air embolus.
Despite these elevated pressures, we have not experi-
enced an increased incidence of air embolism.
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35
Pancreaticoduodenectomy
Lynt B. Johnson, MD and Rupen Amin, MD
INTRODUCTION
A pancreaticoduodenectomy (PD) or Whipple procedure
is one of the most complex general surgical operations.
Owing to the complexity of this procedure, pitfalls that
lead to major complications can occur. In this operation,
experience of the surgeon is paramount to successful out-
comes. This operation is most commonly performed to
remove benign and malignant tumors that involve the
head of the pancreas, duodenum, periampullary region,
or distal common bile duct (CBD). The classic technique
of PD consists of the en-bloc removal of the distal segment
of the stomach (antrum), the rst and second portions of
the duodenum, the head of the pancreas, the distal CBD,
and the gallbladder. Another approach to this procedure
is known as a pylorus-sparing PD. In this approach, a small
segment of duodenum is left in situ with the entire stomach
to preserve the pylorus and prevent postgastrectomy-
related symptoms and complications. The classic Whipple
and pylorus-preserving operations are associated with
comparable operation times, blood loss, hospital stays,
mortality, morbidity, and incidence of delayed gastric
emptying. The overall long-term and disease-free survival
is comparable in both groups. Both surgical procedures
are equally effective for the treatment of pancreatic and
periampullary carcinoma.1
Although the mortality associated with this procedure
has remained low, around 2% at major surgical centers,1
signicant morbidity of 20% to 50% still occurs after this
operation.1,2 Several series have demonstrated that results
are improved when the procedure is performed by high-
volume surgeons, dened as those surgeons that perform
more than 24 procedures per year.3 Common complica-
tions after PD are postoperative pancreatic stula (POPF),
gastroparesis, wound infection, hemorrhage, and pancre-
atitis.1,4 Complications of the procedure generally result
in prolonged hospital stay, delayed adjuvant therapy,
diminished quality of life, or death. The most common
complication after PD is POPF. The occurrence of POPF
with release of autolytic digestion enzymes in the perito-
neal cavity is an underlying source of other complications
such as peripancreatic collections, abscess, and hemor-
rhage.5 Many series have demonstrated stula rates ranging
from 1% to 20%.6,7 The wide range of this reported com-
plication is likely a result of varying denitions of POPF
as well as some patient and surgeon factors. Currently, the
International Study Group Pancreatic Fistula (ISGPF)
denition of POPF remains the most useful for diagnosis.8
This denition includes any amount of drainage uid that
has an amylase level greater than three times the normal
limit of serum amylase. The denition further classies
POPF into subcategories based on the clinical conse-
quences of the stula.6
Risk factors for the development of POPF after PD
include patients with soft texture of the gland, small pan-
creatic ducts, and low preoperative albumin and pre-
albumin.5 In pancreatic adenocarcinoma and chronic
pancreatitis, the pancreas has a more brotic consistency
and is more likely to maintain anastomotic integrity. In
patients with duodenal, neuroendocrine, or small bile
duct tumors, the duct remains small and the gland main-
tains a soft normal gland consistency.5 Small duct size has
also been shown to result in a higher incidence of POPF.
However, duct size may be a surrogate for gland consis-
tency because small ducts are more often seen in patients
with soft glands.
INDICATIONS
Carcinoma of head of the pancreas
Carcinoma of ampulla of Vater
Chronic pancreatitis
Duodenal cancer
Distal bile duct cancer (cholangiocarcinoma)
Cystic tumors of pancreas
OPERATIVE STEPS
Step 1 Laparotomy and exploration
Step 2 Kochers maneuver
Step 3 Cholecystectomy and transection of CBD
Step 4 Division of gastroduodenal artery
Step 5 Ligation of gastrocolic ligament
Step 6 Identication and dissection of superior mesen-
teric vein (SMV)
Step 7 Division of duodenum or stomach
 368 SECTION IV: HEPATOBILIARY SURGERY
Step 8 Division of ligament or Treitz and division of
jejunum
Step 9 Division of neck of pancreas
Step 10 Dissection of portal vein branches from unci-
nate process
Step 11 Division and ligation of branches from superior
mesenteric artery (SMA) to uncinate process
Step 12 Pancreaticojejunostomy
Step 13 Hepaticojejunostomy
Step 14 Duodenojejunostomy or gastrojejunostomy
OPERATIVE PROCEDURE
Kochers Maneuver
Damage to the Inferior Vena Cava or
the Left Renal Vein
The peritoneum overlying the second and third portions
of the duodenum is divided to mobilize the duodenum.
The inferior vena cava (IVC) lies directly posterior to the
pancreatic head and thus can be inadvertently injured if
the dissection does not occur in the correct plane.
Consequence
Excessive bleeding with injury to the anterior wall of
the IVC. Venous bleeding is often more difcult to
control because the venous walls will collapse when
incised.
Grade 3 complication
Repair
The rst thing to do when faced with IVC bleeding is
to remain calm. The second objective is to accurately
visualize the injury before attempting repair. A good
technique is to apply digital pressure for control initially
and then compress the IVC with two sponge sticks
above and below the injury. The IVC wall is often
fragile so one should refrain from attempts to clamp
the injured walls because this can result in an extension
of the injury. Once the injury is visualized, closure with
simple oversewing with monolament suture will repair
the injury.
Prevention
Knowledge of the anatomic position of the IVC with
respect to the duodenum and pancreas is critical. The
relationship is constant. Once the peritoneum is divided,
the index nger of the right hand can be used to
guide the dissection through the loose areolar tissue
behind the duodenum and anterior to the IVC.
Cholecystectomy and Transection of the CBD
Injury to the Right Hepatic Artery
(Normal or Replaced)
In the normal course, the proper hepatic artery bifurcates
to the left of the CBD and the right hepatic artery courses
behind the common hepatic duct to reach the right hepatic
lobe. In almost 20% of patients, the right hepatic artery
will be replaced from the SMA. The replaced right branch
reaches the right hepatic lobe by running parallel and
adjacent to the right side of the CBD in the hilum. The
aberrant replaced right hepatic artery is particularly prone
to injury if not expected.
Consequence
Either excessive bleeding or arterial compromise to the
right hepatic lobe and right intrahepatic biliary tree. On
most occasions, the hepatic ischemia will be limited
and not catastrophic. However, long-term strictures or
necrosis of the right-sided intrahepatic biliary radicles
may occur, resulting in inadequate intrahepatic biliary
drainage or intrahepatic abscesses (Fig. 351).
Grade 3 complication
Repair
End-to-end anastomosis with interrupted ne mono-
lament suture (7-0 or 8-0) should be carried out
under loupe or microscope magnication.
Prevention
Aberrant anatomy to the liver occurs in upward of 30%
of patients. Surgeons should always open the gastrohe-
patic ligament and manually palpate the hilar vessels to
gain an understanding of the arterial supply to the liver.
Knowledge of the course of a replaced hepatic artery is
essential and should guide palpation to the lateral pos-
terior area of the bile duct to ascertain whether there
is a replaced right hepatic artery. Extreme care is taken
to gently dissect the right hepatic artery away from the
wall of the bile duct prior to transection of the CBD.
The replaced right hepatic artery is then dissected prox-
imally to separate it from the areolar tissue holding it
close to the pancreatic head or the injury may recur
when dividing the uncinate process.
Identication and Dissection of the SMV
Injury to the SMV
The SMV is identied at the inferior border of the pan-
creas. Injury to the SMV at this location can be cata-
strophic if it occurs behind the neck of the pancreas.
Consequence
Excessive bleeding.
Grade 3 complication
Repair
Gently lifting the inferior border of the neck of the
pancreas with a vein retractor may expose the injury so
that repair with oversewing of the injury with ne
monolament suture can occur (Fig. 352). If the
injury occurs at the middle of the neck of the pancreas,
packing the injury with hemostatic sponge or gauze
and proceeding with division of the neck of the pan-
creas may then allow for better exposure to repair the
injury.
 35 PANCREATICODUODENECTOMY 369

Pancreas

Superior
mesenteric
vein

Figure 352 The inferior border of the neck of the pancreas is

lifted to visualize the superior mesenteric vein and portal vein. This
maneuver is more easily accomplished with benign tumors.

Prevention
Typically, no branches from the SMV are exactly ante-
rior to the vein. During the dissection, it is paramount
to stay in this orientation and not deviate to either side.
Lifting on the inferior border of the neck of the pan-
creas with a vein retractor will provide some additional
visualization, but inevitably, a portion of the dissection
will be performed without direct visualization to com-
pletely mobilize the neck of the pancreas from the
portal vein and SMV.

Dissection of the Portal Vein Branches from

the Uncinate Process
Portal Vein Injury
Injury to the portal vein most often occurs when the
tumor is closely abutting or adherent to the portal vein.
Consequence
Excessive bleeding or narrowing of the portal vein
leading to portal vein thrombosis.
Grade 3 complication
Repair
The initial goal when bleeding from the portal vein
occurs is to control the bleeding site to visualize the
injury and prepare for repair. Lifting of the head of the
pancreas and vein by placing a hand in the retroperito-
neal space behind the duodenum will often control the
bleeding. If the injury can be easily visualized, repair
with simple oversewing can be performed. However,
often the specimen prevents adequate visualization.
Figure 351 Hepatic infarcts after Whipple resection. Contrast- Thus, if the specimen can be removed while controlling
enhanced axial computed tomography (CT) images demonstrate the bleeding site with digital pressure, this may allow
peripheral geographic areas of diminished attenuation in the liver, for better visualization of the injury and a more satisfac-
most prominent in segment 1. The main portal vein and hepatic tory repair (Fig. 353). The goal of repair of the portal
artery are patent. vein is to prevent narrowing at the closure site. If the
vein cannot be repaired with primary closure, mobiliza-
 370 SECTION IV: HEPATOBILIARY SURGERY
Transected
pancreas
Uncinate
process
Portal vein
Figure 353 Short branches from the portal vein to the uncinate
process must be carefully dissected and secured. Malignant neo-
plasms, especially in the uncinate process, can make this dissection
difcult. In this situation, obtaining control of the portal vein, supe-
rior mesenteric vein, and splenic vein will allow control of hemor-
rhage in the event of branch avulsion.
tion of the portal vein by dividing the peritoneal attach-
ments of the hepatic exure as well as dissecting distally
to free the vein of perihepatic lymphatic and areolar
tissue may allow for repair by complete transection fol-
lowed by an end-to-end anastomosis of the portal vein.
The authors, however, prefer to perform a vein patch
angioplasty at the injury site. Typically, the saphenous
vein is harvested from the groin to create a repair with
a vein patch angioplasty.
Prevention
Branches from the portal vein and SMV are fragile in
nature and are easily torn. Gentle retraction and dissec-
tion of the areolar tissue between the portal vein and
the uncinate process is necessary to prevent injury. If
the tumor is adherent, an early decision to excise part
of the lateral wall of the portal vein and repair with
saphenous vein patch angioplasty will prevent foolhardy
attempts to dissect the tumor away from the portal
vein. If the surgeon anticipates a difcult dissection,
control of the portal vein, SMV, and splenic vein with
vessel loops prior to dissecting the uncinate process
away from the portal vein may allow for rapid control
and minimize blood loss owing to an inadvertent injury
of the portal vein.
Division and Ligation of Branches from
the SMA to the Uncinate Process
SMA Injury
During the nal portion of dissection, the specimen is
freed in the region of the uncinate process. Small branches
for the SMA course through the soft tissue in this area.
Knowledge of these branches and the course of the SMA
is paramount to prevent injury. With large and bulky
tumors, this dissection can be quite perilous because the
tumor may be quite adherent in this area.
Consequence
Excessive blood loss may occur from avulsion of a side
branch of the SMA or direct injury to the SMA itself.
Ligation or clamping of the main SMA will result in
intestinal ischemia with a disastrous outcome if not
easily recognized and repaired.
Grade 3 complication
Repair
The critical maneuver is to lift the SMA with the spec-
imen attached so manual control of the bleeding can
occur. If the injury site is visualized, simple oversewing
of the vessel with monolament suture can be used for
repair. Often, the specimen itself prevents adequate
visualization for repair. In this instance, the remainder
of the specimen dissection will be unnecessary while
maintaining digital or clamp control of the bleeding
site. Often, proximal and distal control with clamps
applied to the SMA is necessary to prevent catastrophic
hemorrhage. Once the specimen is removed, repair
of the vessel can be performed under better
visualization.
Pancreaticojejunostomy
Pancreatic Leak or Postoperative
Pancreatic Fistula
POPF is the most feared complication after a PD proce-
dure. In this situation, amylase-rich uid escapes from the
pancreatic duct owing to a loss of the integrity of the
pancreatic to jejunal or gastric anastomosis. The release of
autodigestive enzymes in the peritoneal cavity can lead to
other secondary complications. Some series have reported
that intra-abdominal abscess has been related to POPF in
50% to 60% of cases.5,912
Consequence
POPF can result in abscess, sepsis, and mortality in its
severest form. However, if handled properly, POPF
does not necessarily present serious clinical conse-
quences. Recently, the ISGPF devised a classication
system for POPF. The complication is graded as A, B,
or C, depending on the consequences of the POPF
grade A: biochemical stula without clinical sequelae;
grade B: stula requiring any therapeutic intervention;
and grade C: stula with severe clinical sequelae.13
Grade A stulas occurred 15% of the time; grade B,
12%; and grade C, 3%.14
Grade 3 complication
Repair
Reoperation for POPF is generally unnecessary unless
an undrained uid collection is unattainable by percu-
taneous drainage. If reoperation is necessary, control-
ling the stula with a closed-suction drain is typically
 35 PANCREATICODUODENECTOMY 371

all that is necessary. A few buttress repair sutures can

be placed if the site of the leak is obvious, but dedicated
attempts to locate the stula site with aggressive dis-
section is unnecessary and often will result in further
damage or disruption. Patients with the clinical diag-
nosis of pancreatic stula usually undergo a computed
tomography (CT) scan to assess for associated abscess
formation, but approximately 80% of stulas heal with
conservative management.4 Ten percent to 15% of
patients with pancreatic stulas require percutaneous
drainage, whereas only 5% require repeat surgery.4

Prevention
Numerous strategies have been employed to prevent
POPF. Accurate suture placement by an experienced
pancreatic surgeon is warranted. Whether one chooses
a duct-to-mucosa two-layered anastomosis or a single-
layered dunking technique does not seem to differ in
the occurrence of POPF. Other strategies have included
the use of octreotide, although the effect has been vari- Figure 354 Pseudoaneurysm of hepatic artery jump graft after
able in different reported series. In addition, it appears Whipple resection. Immediate postoperative contrast-enhanced
that a standardized approach to the pancreatic anasto- axial CT image shows peripancreatic inammation.
mosis and a consistent practice of a single technique
can help to reduce the incidence of complications
after PD.15

Other Complications
Foregut Ischemia due to Ligation of the
Gastroduodenal Artery in Patients with Celiac
Artery Stenosis or Occlusion
An unusual but potentially devastating complication can
occur in patients who undergo a Whipple procedure who
have celiac artery stenosis or occlusion. This can occur in
patients with atherosclerotic disease or arcuate ligament
syndrome. In this situation, the blood supply to the liver
and pancreas will be supplied by retrograde ow through
the gastroduodenal artery via collaterals from the SMA. If
unrecognized, division of the gastroduodenal artery will
result in foregut ischemia.
Consequence Figure 355 Pseudoaneurysm of hepatic artery jump graft after
Whipple resection. Follow-up CT 3 weeks later shows complex
Liver, pancreatic, and stomach ischemia.
uid in the lesser sac, consistent with blood products.
Grade 4/5 complication
Repair Prevention
Aorta to hepatic artery bypass graft with saphenous vein A thorough review of the visceral vessel anatomy with
is necessary in most cases. If the stenosis is recognized preoperative imaging can demonstrate signicant nar-
preoperatively, endovascular dilation and stenting may rowing of the celiac axis.
prevent the need for bypass and ischemic insult to the
aforementioned organs. If a bypass graft is necessary, Delayed Gastric Emptying
strong consideration should be given to performing a Delayed gastric emptying is dened as the persistent
completion pancreatectomy to prevent the need for a need for a nasogastric tube for longer than 10 days and
tenuous pancreaticojejunostomy. In this situation, the is seen in 11% to 29% of patients.1618 This is one of the
risk of leak from the pancreatic anastomosis can lead to most common complications after PD. Most cases occur
devastating complications of abscess, sepsis, or pseu- owing to edema at the anastomosis or dysmotility after
doaneurysm owing to disruption of the pancreatic partial gastrectomy and loss of the duodenal pacemaker.
enteric anastomosis (Figs. 354 to 357). The classic Whipple and pylorus-sparing operations are
 372 SECTION IV: HEPATOBILIARY SURGERY
Figure 356 Pseudoaneurysm of hepatic artery jump graft after
Whipple resection. On a more inferior image, a pseudoaneurysm
of the hepatic artery is seen as a new nding.
Figure 357 Pseudoaneurysm of hepatic artery jump graft after
Whipple resection. A multiplanar reformatted image demonstrates
the pseudoaneurysm of the hepatic artery and associated
hematoma.
associated with comparable operation times, blood loss,
hospital stays, mortality, morbidity, and more importantly,
incidence of delayed gastric emptying.1,19 The incidence
of delayed gastric emptying can possibly be reduced
by shortening the operative time and using antecolic
duodenojejunostomy.20
Hemorrhage
Hemorrhage in the postoperative period occurs in approx-
imately 7% of patients. Endoluminal hemorrhage gener-
ally requires endoscopic evaluation or arteriography with
embolization.21 Early intraperitoneal hemorrhage gener-
ally requires urgent surgical exploration. Delayed hemor-
rhage is often best managed with arteriography and
embolization if the site can be identied. Post-PD
pancreatitis is rarer, occurring in fewer than 5% of
patients.17,18
OVERALL MORBIDITY
AND MORTALITY
Many questions remain regarding the morbidity and mor-
tality associated with the two different approaches to this
complicated procedure. Several studies clearly demon-
strated no statistical difference in morbidity between the
two types of procedures. Further, the overall mortality of
this procedure remains steady at approximately 3%, but no
difference in mortality has been described between the
two different approaches to this procedure. Therefore,
pylorus-preserving PD is an acceptable alternative to the
classic Whipple procedure in the treatment of periampul-
lary cancer. Long-term survival and type of recurrence are
not inuenced by selection of surgical procedures.2225
REFERENCES
1. Tran KT, Smeenk HG, van Eijck CH, et al. Pylorus
preserving pancreaticoduodenectomy versus standard
Whipple procedure: a prospective, randomized, multi-
center analysis of 170 patients with pancreatic and
periampullary tumors. Ann Surg 2004;240:738745.
2. Crist DW, Sitzmann JV, Cameron JL. Improved hospital
morbidity, mortality, and survival after the Whipple
procedure. Ann Surg 1987;206:358365.
3. Urbach DR, Bell CM, Austin PC. Differences in operative
mortality between high- and low-volume hospitals in
Ontario for 5 major surgical procedures: estimating the
number of lives potentially saved through regionalization.
CMAJ 2003;168:14091414.
4. Gervais DA, Fernandez-del Castillo C, ONeill MJ, et al.
Complications after pancreatoduodenectomy: imaging and
imaging-guided interventional procedures. Radiographics
2001;21:673690.
5. Crippa S, Bassi C, Salvia R, et al. Enucleation of pancre-
atic neoplasms. Br J Surg 2007;94:12541259.
6. Bassi C, Dervenis C, Butturini G, et al. Postoperative
pancreatic stula: an International Study Group Pancreatic
Fistula (ISGPF) denition. Surgery 2005;138:813.
7. Kazanjian KK, Hines OJ, Eibl G, et al. Management of
pancreatic stulas after pancreaticoduodenectomy: results
in 437 consecutive patients. Arch Surg 2005;140:849
854; discussion 5456.
8. Liang TB, Bai XL, Zheng SS. Pancreatic stula after
pancreaticoduodenectomy: diagnosed according to
International Study Group Pancreatic Fistula (ISGPF)
denition. Pancreatology 2007;7:325331.
9. Li-Ling J, Irving M. Somatostatin and octreotide in the
prevention of postoperative pancreatic complications and
the treatment of enterocutaneous pancreatic stulas: a
systematic review of randomized controlled trials. Br J
Surg 2001;88:190199.
10. Popiela T, Kedra B, Sierzega M, et al. Risk factors of
pancreatic stula following pancreaticoduodenectomy for

periampullary cancer. Hepatogastroenterology
2004;51:14841488.
11. Buchler MW, Friess H, Wagner M, et al. Pancreatic stula
after pancreatic head resection. Br J Surg 2000;87:883
889.
12. Balsam JH, Ratter DW, Warsaw AL, et al. Ten-year
experience with 733 pancreatic resections: changing
indications, older patients, and decreasing length of
hospitalization. Arch Surg 2001;136:391398.
13. Pratt W, Maithili SK, Vanounou T, et al. Postoperative
pancreatic stulas are not equivalent after proximal, distal,
and central pancreatectomy. J Gastrointest Surg
2006;10:12641278; discussion 12781279.
14. Pratt WB, Maithel SK, Vanounou T, et al. Clinical and
economic validation of the International Study Group of
Pancreatic Fistula (ISGPF) classication scheme. Ann Surg
2007;245:443451.
15. Shrikhande SV, Barreto G, Shukla PJ. Pancreatic stula
after pancreaticoduodenectomy: the impact of a standard-
ized technique of pancreaticojejunostomy. Langenbecks
Arch Surg 2008;393:8791.
16. Fernandez-del Castillo C, Rattner DW, Warshaw AL.
Standards for pancreatic resection in the 1990s. Arch Surg
1995;130:295299; discussion 299300.
17. Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fty
consecutive pancreaticoduodenectomies in the 1990s:
pathology, complications, and outcomes. Ann Surg 1997;
226:248257; discussion 257260.
35 PANCREATICODUODENECTOMY 373
18. Barens SA, Lillemoe KD, Kaufman HS, et al. Pancreatico-
duodenectomy for benign disease. Am J Surg 1996;171:
131134; discussion 134135.
19. van Berge Henegouwen MI, van Gulik TM, DeWit LT,
et al. Delayed gastric emptying after standard pancreatico-
duodenectomy versus pylorus-preserving pancreaticoduo-
denectomy: an analysis of 200 consecutive patients. J Am
Coll Surg 1997;185:373379.
20. Gao HQ, Yang YM, Zhuang Y, et al. [Inuencing factor
analysis of delayed gastric emptying after pylorus-preserv-
ing pancreaticoduodenectomy]. Zhonghua Wai Ke Za Zhi
2007;45:10481051.
21. Rumstadt B, Schwab M, Korth P, et al. Hemorrhage
after pancreatoduodenectomy. Ann Surg 1998;227:236
241.
22. Pellegrini CA, Heck CF, Raper S, et al. An analysis of the
reduced morbidity and mortality rates after pancreatico-
duodenectomy. Arch Surg 1989;124:778781.
23. Itani KM, Coleman RE, Meyers WC, et al. Pylorus-
preserving pancreatoduodenectomy. A clinical and
physiologic appraisal. Ann Surg 1986;204:655664.
24. Takao S, Aikou T, Shinchi H, et al. Comparison of relapse
and long-term survival between pylorus-preserving and
Whipple pancreaticoduodenectomy in periampullary
cancer. Am J Surg 1998;176:467470.
25. Grace PA, Pitt HA, Tompkins RK, et al. Decreased
morbidity and mortality after pancreatoduodenectomy.
Am J Surg 1986;151:141149.
36
Distal Pancreatectomy
Kiran K. Dhanireddy, MD
and Thomas M. Fishbein, MD
INTRODUCTION
Distal pancreatectomy is performed for a variety of benign
and malignant indications. The tail of the pancreas can be
resected for lesions that are to the left of the superior
mesenteric vessels. The procedure can be performed with
or without splenic preservation, depending on the initial
indication and intraoperative ndings. Pancreatic malig-
nancy generally requires splenectomy, whereas benign
indications for distal pancreatectomy allow for splenic
preservation. Although the ultimate outcome of the pro-
cedure depends on the underlying disease process, the
complications associated with distal pancreatectomy are
readily avoided through an intimate knowledge of pancre-
atic anatomy and meticulous surgical technique. The most
discussed complication of pancreatic surgery is pancreatic
leak and stula13; however, several additional pitfalls to
be avoided in the course of executing distal pancreatec-
tomy will also limit postoperative morbidity and mortality.
Whereas laparoscopic distal pancreatectomy with or
without splenic preservation is currently possible, specic
discussion of the laparoscopic aspects of this operation are
beyond the scope of this chapter.47
INDICATIONS
Pancreatic adenocarcinoma
Benign cystadenoma
Cystadenocarcinoma
Neuroendocrine tumor
Traumatic pancreatic duct disruption
Pancreatic pseudocyst
Chronic pancreatitis
Acute pancreatic necrosis
OPERATIVE STEPS
Step 1 Incision
Step 2 Entry into lesser sac and exposure of
pancreas
Step 3 Dissection of inferior border of pancreatic tail
Distal Pancreatectomy with Splenectomy
Step 4a Splenic mobilization
Step 5a Medial rotation of spleen and tail of
pancreas
Step 6a Ligation of splenic vessels
Splenic Preservation
Step 4b Vascular control of splenic vessels medial to
lesion
Step 5b Ligation of perforating branches of splenic
vein and artery
Step 7a/6b Pancreatic division
Step 8a/7b Drain placement and closure of abdomen
OPERATIVE PROCEDURE
Incision
The patient should be in the supine position on the oper-
ative table in slight reverse Trendelenburg. Either an
upper midline or a left subcostal incision may be used
because both provide excellent exposure of the pancreas.
The midline incision may be preferable when the patient
has a narrow costal arch, whereas the subcostal incision is
superior in patients in whom the costal arch is wide.
Entry into the Lesser Sac and Exposure of
the Pancreas
To enter the lesser sac, the gastrocolic ligament is divided
in a relatively avascular area. The anterior surface of the
pancreas is then fully exposed. Occasionally, the inferior
short gastric vessels must be ligated to facilitate full expo-
sure of the tip of the pancreatic tail. This has no implica-
tion for splenic function if the spleen is preserved.
Hemorrhage from the Veins Communicating
between the Right Gastroepiploic Vessels and
the Middle Colic Vein
Occasionally, a branch of the right gastroepiploic vessels
will communicate with the middle colic vessels inferior to
the pylorus. In the process of elevating the stomach, this
vein may be torn.
 376 SECTION IV: HEPATOBILIARY SURGERY
Consequence
Unnecessary blood loss can obscure the operative eld
and prolong the course of the operation.
Grade 1 complication
Repair
Ligation of the torn ends of the vessel.
Prevention
Prior to elevating the antrum and pylorus of the
stomach, all vascular attachments should be identied
and ligated using silk or Vicryl ties of the appropriate
caliber. Entering through the gastrocolic omentum in
the correct avascular plane and continuing toward the
short gastric vessels to the spleen will help avoid this
complication.
Dissection of the Inferior Border of
the Pancreatic Tail
After the pancreas has been fully exposed, the peritoneum
overlying the inferior margin of the pancreatic tail is
incised. This maneuver allows for superior reection of the
pancreas and exposure of the splenic vessels.
Injury to the Middle Colic Vein or the Inferior
Mesenteric Vein
The middle colic vein runs in the transverse mesocolon in
close proximity to the inferior border of the pancreas. This
vein may be encountered during the medial portion of the
dissection. Similarly, the inferior mesenteric vein may be
encountered more laterally as it drains into the splenic
vein.
Consequence
Unnecessary blood loss and increased operative time
are the consequences of unrecognized middle colic and
inferior mesenteric vein injury.
Grade 1 complication
Repair
The middle colic and inferior mesenteric veins may be
ligated if they are injured because there is a rich network
of collateral venous drainage for the large intestine.
Prevention
During the course of dissection, these vessels should be
identied and spared injury. Dissection of the pancre-
atic tail should proceed from distally (near the spleen)
toward the body. Identication of the splenic vein
along the inferior margin of the pancreas allows one to
directly identify where these veins will potentially enter,
avoiding injury.
Splenic Mobilization
If the spleen is not to be preserved during the conduct of
the operation, the attachments, including the leinocolic,
splenorenal, and splenogastric ligaments, must be fully
mobilized.
Bleeding from the Spleen
Consequence
The spleen has a rich blood supply from both the
splenic artery and the short gastric vessels. Injury to the
splenic capsule or failure to recognize all the short
gastric vessels can result in bothersome bleeding.
Grade 1 complication
Repair
Meticulous ligation of the short gastric vessels will
control bleeding from these vessels.
Prevention
Ligation of the splenic artery at the hilum of the spleen
early in the course of mobilization will limit blood loss
if splenic injury occurs. Argon beam coagulation or
other local measures can temporarily halt splenic cap-
sular or ligamentous bleeding.
Medial Reection of the Spleen and
the Tail of the Pancreas
After the splenic attachments have been released, the
spleen and tail of the pancreas may be rotated medially.
The attachments of the pancreatic tail to the retroperito-
neum are avascular and can therefore be freed using a
combination of gentle blunt and sharp dissection. The
splenic vessels are included in the mobilization.
Injury to the Left Renal Vein or the Adrenal Vein
The left renal vein lays posterior to the inferior margin of
the tail of the pancreas (Fig. 361). The left adrenal vein
enters the superior surface of the renal vein, and the
adrenal gland can sometimes be adherent to the posterior
Adrenal Spleen
IVC
Renal vein Kidney
Pancreas
Figure 361 Hidden anatomy relationship of left renal vein/left
adrenal vein to tail of pancreas.

capsule of the pancreas, making this mobilization of the
pancreas more difcult. During the course of medial
reection, the left renal vein, adrenal gland, or adrenal
vein may be inadvertently injured.
Consequence
Renal vein injury can result in brisk bleeding and
signicant blood loss. Based on the severity of the
laceration, a signicant prolongation of the operative
procedure may result. If a branch of the renal vein is
inadvertently ligated and unrecognized, venous con-
gestion and subsequent loss of renal function may
result. The left adrenal gland may be controlled with
electrocautery, and the vein may be ligated without
consequence.
Grade 1/2 complication
Repair
The left renal vein should be repaired primarily using
a nonabsorbable monolament suture such as Prolene.
This requires vascular control of the vein proximally
and distally. This may be facilitated by ligation of the
left gonadal vein and retroperitoneal collateral vein
from the left renal vein in order to gain mobility for
repair with good visualization.
Prevention
Knowledge of the relationship between the left renal
vein and the tail of the pancreas along with careful dis-
section during the course of medial reection will
prevent this complication.
Ligation of the Perforating Branches of
the Splenic Vein and Artery
If the spleen is to be preserved during the conduct of the
operation, the splenic artery and vein must be separated
from the tail of the pancreas (Fig. 362). The blood
Spleen
Pancreas
Figure 362 Small vessels directly from splenic vessels to tail of
pancreas. Note added branches from splenic vein.
36 DISTAL PANCREATECTOMY 377
supply to the tail of the pancreas consists of multiple per-
forating vessels directly from the splenic vessels.
Bleeding from the Pancreatic Branches of
the Splenic Vessels
These vessels must be carefully dissected and ligated with
small clips, suture ligature, or harmonic scalpel. If an
unsecured vessel is transected, the vessel may retract out
of the operative eld and cause bleeding that is difcult
to control.
Consequence
Unnecessary blood loss and prolonged operative time
will result from bleeding branches of the splenic
vessels.
Grade 1 complication
Repair
Identication and ligation of the bleeding vessels halts
blood loss. The pancreatic side is best controlled with
ne monolament suture, whereas the splenic vein side
may be tied or sutured if it tears.
Prevention
Early vascular control of the splenic vessels proximal
to the site of proposed pancreatic transection allows
for minimization of any bleeding from the perforating
vessels. The use of suture ligation of these very short
branches with ne Prolene may speed the conduct of
the operation.
Pancreatic Division
The pancreatic parenchyma can be divided using a gastro-
intestinal anastomosis (GIA) stapler with a vascular load
or using nonabsorbable horizontal mattress sutures. Data
suggest that the incidence of complications is lower in
stapled transections.8
Pancreatic Leak/Fistula
Pancreatic stula after distal pancreatectomy is reported
to occur in approximately 25% of patients.9,10 This com-
plication adds signicant morbidity and mortality to the
operation.
Consequences
Pancreatic stula infrequently necessitates reoperation
but does add signicantly to length of hospital stay, the
need for parenteral nutrition, and overall costs.7
Grade 4 complication
Repair
Few would advocate direct repair of the pancreatic
stump for management of a pancreatic stula. Current
strategies include drainage and the use of parenteral
nutrition to prevent pancreatic stimulation by enteral
diet. The use of a somatostatin analogue has been
examined as a means to decrease the production of
 378 SECTION IV: HEPATOBILIARY SURGERY
pancreatic enzymes.11 Low-volume leaks usually seal
with drainage alone, whereas those stulas with high-
volume output are likely to seal with a period of pro-
longed parenteral nutrition in the absence of oral
intake.
Prevention
There have been numerous reports of strategies to
reduce the risk of pancreatic leak after distal pancreatec-
tomy. Most of these techniques have been unsuccess-
ful. For example, the use of brin glue had been
advocated but has recently been shown to not signi-
cantly change the rate of stula development.12 Another
technique that might alter the rate of stula develop-
ment is direct ligation of the pancreatic duct, even if a
stapler is used for transecting the pancreatic tissue.13
The mainstay of treatment is closed-suction drainage
of the pancreatic bed after surgery, the institution of a
low-fat diet, and the judicious use of antibiotics to treat
superinfection when it occurs.
REFERENCES
1. Rodriguez JR, Germes SS, Pandharipande PV, et al.
Implications and cost of pancreatic leak following distal
pancreatic resection. Arch Surg 2006;141:361365.
2. Kuroki T, Tajima Y, Kanematsu T. Surgical management
for the prevention of pancreatic stula following distal
pancreatectomy. J Hepatobiliary Pancreat Surg 2005;12:
283285.
3. Knaebel HP, Diener MK, Wente MN, et al. Systematic
review and meta-analysis of technique for closure of the
pancreatic remnant after distal pancreatectomy. Br J Surg
2005;92:539546.
4. Toniato A, Meduri F, Foletto M, et al. Laparoscopic treat-
ment of benign insulinomas localized in the body and tail
of the pancreas: a single-center experience. World J Surg
2006;30:19161919.
5. Palanivelu C, Shetty R, Jani K, et al. Laparoscopic distal
pancreatectomy: results of a prospective non-randomized
study from a tertiary center. Surg Endosc 2007;4:250
254.
6. Aluka KJ, Long C, Rickford MS, et al. Laparoscopic distal
pancreatectomy with splenic preservation for serous
cystadenoma: a case report and literature review. Surg
Innov 2006;13:94101.
7. Pierce RA, Spitler JA, Hawkins WG, et al. Outcomes
analysis of laparoscopic resection of pancreatic neoplasms.
Surg Endosc 2007;4:579586.
8. Takeuchi K, Tsuzuki Y, Ando T, et al. Distal pancreatec-
tomy: is staple closure benecial? Aust N Z J Surg 2003;
73:922925.
9. Fahy BN, Frey CF, Ho HS, et al. Morbidity, mortality,
and technical factors of distal pancreatectomy. Am J Surg
2002;183:237241.
10. Pannegeon V, Pessaux P, Sauvanet A, et al. Pancreatic
stula after distal pancreatectomy: predictive risk factors
and value of conservative treatment. Arch Surg 2006;141:
10711076.
11. Suc B, Msika S, Piccinini M, et al, and the French
Associations for Surgical Research. Octreotide in the
prevention of intra-abdominal complications following
elective pancreatic resection: a prospective, multicenter
randomized controlled trial. Arch Surg 2004;139:288
294.
12. Suc B, Msika S, Fingerhut A, et al, and the French
Associations for Surgical Research. Temporary brin glue
occlusion of the main pancreatic duct in the prevention of
intra-abdominal complications after pancreatic resection:
prospective randomized trial. Ann Surg 2003;237:57
65.
13. Bilimoria MM, Cormier JN, Mun Y, et al. Pancreatic leak
after left pancreatectomy is reduced following main
pancreatic duct ligation. Br J Surg 2003;90:190196.
37
Lateral Pancreaticojejunostomy
(Puestow) Procedure
Eleanor Faherty, MD and Patrick G. Jackson, MD
INTRODUCTION
Surgical approaches to chronic pancreatitis are indicated
in the setting of intractable pain or anatomic complica-
tions of the disease process, such as symptomatic obstruc-
tion of the common bile duct, pancreatic duct, or
duodenum. From a conceptual standpoint, the surgical
procedures offered for chronic pancreatitis can be segre-
gated into resection procedures, drainage procedures, or
combinations of the two. The specic approach to surgi-
cal management must be individualized because there is a
wide variability in symptomatology, gland pathology, and
anatomic manifestation.1
Ductal drainage procedures are used for patients with
dilated pancreatic ductal systems, under the theory that
the pancreatic duct has a symptomatic and functional
obstruction. With a limitation to enzyme secretion into
the duodenum, there is a lack of inhibitory feedback,
thus allowing an increase in cholecystokinin, which
induces further enzyme secretion into a functionally
obstructed duct. The increased ductal distention then
causes pain.2
No clear consensus exists regarding the denition of
a dilated ductal system. Whereas most would agree that
pancreatic ducts greater than 1 cm (Fig. 371) consti-
tute sufcient dilation, greater controversy exists regard-
ing ducts between 5 mm and 1 cm.1,3 Although no
prospective study exists correlating greater ductal size
with superior long-term outcome, increased ductal dila-
tion does facilitate a number of the steps in the proce-
dure. Surgical management of chronic pancreatitis and
ductal drainage is technically challenging, requiring a
comprehensive and coherent surgical approach to avoid
common pitfalls.
INDICATIONS
Intractable abdominal pain and/or back pain
Symptomatic duodenal obstruction
Symptomatic common bile duct obstruction
OPERATIVE STEPS
Step 1 Skin incision
Step 2 Exploration of peritoneal contents for additional
pathology
Step 3 Enter lesser sac to expose anterior pancreas
Step 4 Wide Kocher maneuver
Step 5 Location of pancreatic duct with palpation and
needle aspiration
Step 6 Unroong of pancreatic duct from duodenum
to splenic hilum
Step 7 Ensure adequate pancreatic drainage
Step 8 Construction of Roux-en-Y jejunal loop of
approximately 60 cm
Step 9 Anastomosis of Roux-en-Y loop in retrocolic,
two-layer, side-to-side pancreaticojejunostomy
Step 10 Fixation of Roux-en-Y jejunal loop to transverse
mesocolon
Step 11 Closure4,5
OPERATIVE PROCEDURE
Exploration of Peritoneal Contents for
Additional Pathology
Unexpected Intraoperative Findings
Consequence
Change in operative strategy.
Grade 1/2 complication
Repair
Appropriate surgical management of another disease
process such as pancreatic cancer.
Prevention
Preoperative planning in the management of chronic
pancreatitis is critical to success. Noninvasive imaging
with high-quality dynamic bolus-enhanced computed
tomography (CT) with thin cuts to evaluate the
pancreas helps avoid errors in the management algo-
rithm. Pancreatic cancers will generally appear as
 380 SECTION IV: HEPATOBILIARY SURGERY
Figure 371 Dilated pancreatic duct with parenchymal
calcications.
hypodense lesions. Preoperative CT scans can also
delineate biliary ductal dilation, pseudocysts, and
pancreatic duct size.1 Endoscopic retrograde cholan-
giopancreatography (ERCP) can provide valuable
information about intraductal pathology and should be
used when the diagnosis of chronic pancreatitis is in
doubt, to evaluate possible ampullary lesions, or to
assess duct size if CT cannot provide adequate informa-
tion. Endoscopic ultrasound (EUS), a newer diagnostic
technique, is the most sensitive modality for the diag-
nosis of pancreatic carcinoma, and although it is inva-
sive, it poses fewer risks than ERCP.4 With its ability
to assess the pancreatic parenchyma and determine
duct size and an increased sensitivity for mass lesions,
EUS is becoming a valuable tool in the preoperative
planning of chronic pancreatitis management.
Enter the Lesser Sac to Expose
the Anterior Pancreas and Perform a Wide
Kocher Maneuver
Inadequate Exposure
Consequence
Technical inability to complete the procedure.
Grade 2/3 complication
Repair
Appropriate exposure of the abdomen and the anterior
surface of the entire pancreas.
Prevention
A generous midline incision is employed for the proce-
dure, and the entire abdomen is explored. A wide
Kocher maneuver helps in the exposure of the head of
the pancreas. The gastrocolic ligament is divided to
enter the lesser sac with subsequent mobilization of the
stomach superiorly and the transverse colon inferiorly.
Figure 372 Needle aspiration of dilated duct system.
The posterior wall of the stomach may be densely
adhered to the pancreas and will require meticulous
dissection in the avascular place for separation. Critical
in this step is exposure of the entire anterior surface of
the pancreas, with careful preservation of the gastro-
epiploic vessels.6
Location of the Pancreatic Duct with Palpation
and Needle Aspiration and Unroong of
the Pancreatic Duct from the Duodenum to
the Splenic Hilum
Inability to Identify the Pancreatic Duct
Consequence
Bleeding or inadvertent injury to the pancreatic
parenchyma.
Grade 2/3/4 complication
Repair
Hemostasis and wide postoperative drainage.
Prevention
The pancreatic duct can usually be palpated as a soft
compressible area in the body of the gland. Intraop-
erative ultrasound should be used liberally to conrm
the identication of the duct and thus avoid unwar-
ranted pancreatotomy. Accessory or side branch ducts
may also be dilated, so aspiration of clear secretions
does not conrm location of the main duct (Fig. 372).
With intraoperative ultrasound, a needle can be easily
placed into the pancreatic duct by aspiration, with the
syringe then removed, leaving the needle in the duct
to serve as a guide.
 37 LATERAL PANCREATICOJEJUNOSTOMY (PUESTOW) PROCEDURE
Aggressive Attempts to Identify and
Open the Duct
Consequence
Injury to the superior mesenteric vein/portal vein.
Grade 2/3/4 complication
Repair
Meticulous hemostasis using ne sutures.
Prevention
Clear and careful identication of the superior mes-
enteric vein during exposure of the pancreas will help
avoid this potentially disastrous event. In addition, the
duct should be entered using electrocautery through
its anterior surface at the midbody, thus avoiding the
splenoportal conuence.6
Ensure Adequate Pancreatic Drainage
Insufcient Decompression
Consequence
Anastomotic stricture, reduced likelihood of symptom-
atic relief.
Grade 2/3/4 complication
Repair
Further endoscopic or surgical procedures to decom-
press the ductal system.
Prevention
Using the needle as a guide, the pancreatic duct is
opened. Once the pancreatotomy is sufcient to allow
passage of a ne right-angle clamp or probe, the course
of the duct can be determined (Fig. 373). This allows
incision of the overlying pancreatic parenchyma. All
Figure 373 Right angle clamp used to extend pancreatic duct
incision.
381
intraductal concretions must be removed.4 The entire
duct from tail to head should be opened to allow suf-
cient drainage of the entire pancreatic parenchyma
(Fig. 374). Studies suggest that a pancreaticojejunos-
tomy less than 6 cm in length has a higher risk of
stricture and therefore inadequate drainage.7 Although
this is factually correct, focusing too heavily on the
minimum requirement fails to emphasize the goal of
adequate decompression of the entire pancreas because
the minimum requirement becomes the denition of
adequacy. Therefore, unroong of the entire duct from
tail to head with subsequent longitudinal pancreatico-
jejunostomy will provide sufcient drainage.
Anastomosis of the Roux-en-Y Loop in
a Retrocolic, Two-Layer, Side-to-Side
Pancreaticojejunostomy
Inadequate Orientation of the Roux-en-Y Limb
Consequence
Difculty in subsequent biliary decompression.
Grade 2/3 complication
Repair
Additional biliary enteric bypass limb.
Prevention
The blind end of the Roux-en-Y limb used for pancre-
aticojejunostomy should be oriented toward the splenic
hilum (Fig. 375). Orientation in the opposite direc-
tion will not allow for decompression of the biliary tree,
should this prove necessary later. With orientation of
the blind end toward the spleen, additional length of
this limb can be drawn through the rent in the trans-
verse mesocolon for creation of a tension-free biliary
enteric anastomosis if necessary.1
Figure 374 Exposure of entire length of pancreatic duct.
 382 SECTION IV: HEPATOBILIARY SURGERY
Figure 375 Construction of pancreaticojejunostomy.
Leak from the Pancreaticojejunostomy
Consequence
Intra-abdominal autodestruction from activated pan-
creatic enzymes.
Grade 2/3 complication
Repair
Wide drainage with prolonged bowel rest.
Prevention
Given the brotic parenchymal changes from chronic
pancreatitis, leak from this anastomosis should be
unusual. The outer layer on the inferior side is sewn
rst, using nonabsorbable interrupted sutures. Next,
the jejunum is incised, and a running inner layer of
absorbable suture is begun at the distal pancreatic tail
and extended to the head. The superior inner layer is
run in a similar fashion from tail to head. The nal
superior outer layer is completed using nonabsorbable
interrupted sutures.4 A duct-to-mucosa anastomosis is
not necessary and may compromise the overall drainage
in areas of stricture.5 Wide drainage using soft Silastic
drains will help to minimize the physiologic conse-
quence of an anastomotic leak.
REFERENCES
1. Prinz R. Pancreatic duct drainage. In Pancreas. p 829.
2. Owyang C. Control of exocrine pancreatic secretion. Regul
Pept 1989;1:107.
3. Prinz RA. Surgical options in chronic pancreatitis. Int J
Pancreatol 1993;14:97105.
4. Nakeeb A, Lillemoe K, Cameron JL. Procedures for benign
and malignant pancreatic disease. In Souba WS (ed): ACS
Surgery: Principles and Practice. Hamilton, Ontario: BC
Decker, 2008.
5. Sakorafas GH, Sarr MG. Tricks in the technique of lateral
pancreaticojejunostomy. Eur J Surg 2000;166:498500.
6. Nealon WH, Thompson JC. Progressive loss of pancreatic
function in chronic pancreatitis is delayed by main pancre-
atic duct decompression. A longitudinal analysis of the
modied Puestow. Ann Surg 1993;217:458468.
38
Pancreatic Cyst/Debridement
Lynt B. Johnson, MD, Patrick G. Jackson, MD,
and Trevor Upham, MD
Inammatory
Pancreatic Cyst
Drainage
Lynt B. Johnson
INTRODUCTION
Cysts of the pancreas are typically inammatory in nature
or neoplastic. Pancreatic pseudocysts generally occur as a
consequence of acute or chronic pancreatitis. Unlike pseu-
docysts of the pancreas due to chronic pancreatitis, pseu-
docysts that occur as a result of acute pancreatitis more
often can spontaneously resolve over time; however, some
of these cysts persist and require intervention. Distinction
should be made between a pancreatic pseudocyst with a
low viscous liquid uid and other peripancreatic collec-
tions that include phlegmons and tissue necrosis, which
are more semisolid or solid in consistency. The consis-
tency of the material encountered greatly inuences the
appropriate treatment options. Typically for noninfected
collections, it is prudent to wait 6 weeks from the inam-
matory incident to allow time for the cyst to resolve or
for the cyst wall to mature. During this 6-week period,
the consistency of the uid can change dramatically from
a toothpaste consistency to pure liquid. The diagnosis of
the pseudocyst is typically identied through abdominal
imaging. Computed tomography, magnetic resonance
imaging, or ultrasound can be used to conrm the diag-
nosis. One must be cautious to not misdiagnose a cystic
neoplasm as a pseudocyst. Suspicion of the diagnosis
should occur if there has not been a precedent history of
pancreatitis. Clinical signs of infection such as fevers and
gas within the collection often warrant early intervention.
Although studies utilizing percutaneous drainage as well
as endoscopic drainage have reported some success, the
selection of the appropriate patient for these treatments is
paramount. In general, patients with semisolid or solid
components in the collection should be managed with
operative drainage. The choices for operative drainage
include internal drainage by cystenterostomy or external
drainage. Internal drainage is preferred when the cyst
is not infected and has low-viscosity uid. For giant pseu-
docysts, the author prefers a Roux-en-Y cystgastrostomy
performed through the transverse mesocolon. This allows
for complete resolution of the cyst through dependent
drainage. Although cystgastrostomy is regarded as a main-
stay for internal drainage cases, stasis and retroperitoneal
sepsis have occurred, especially in large pseudocysts,
owing to lack of adequate dependent drainage. External
drainage can also be accomplished through a transverse
mesocolon approach for patients with phlegmons or
infected pseudocysts to allow for manual dbridement of
the necrotic tissue and placement of large-caliber drains.
Cystgastrostomy or
Endoscopic Drainage
INDICATIONS
Small, less than 5 cm persistent pseudocyst located pos-
terior to stomach
Low viscosity of cyst uid
OPERATIVE STEPS
Step 1 Anterior gastrotomy
Step 2 Creation of posterior gastrotomy
Step 3 Cyst wall and posterior stomach anastomosis
Step 4 Closure of anterior gastrotomy
OPERATIVE PROCEDURE
Anterior Gastrotomy
Anterior Gastrotomy Bleeding
Typically, a transverse incision using electrocautery directly
overlying the cyst should be made. The gastric wall is very
vascular, and thus, bleeding can occur if other nonhemo-
static incisions are made in the stomach wall.
 384 SECTION IV: HEPATOBILIARY SURGERY

Consequence verse mesocolon, one can identify the pseudocyst bulging

Bleeding can occur and obscure adequate vision. through the mesocolon. If not, apply the same maneuvers
Grade 1 complication as listed previously.
Injury to the Mesocolon Vessels
Repair
Oversewing of the gastrotomy edges typically will Consequence
control the bleeding. Hemorrhage.
Grade 1 complication
Prevention
Alternatively, the gastrotomy can be performed with a Repair
dividing stapling device. Oversewing of the bleeding vessel should control the
bleeding. If it occurs from the pancreatic bed, over-
sewing of the vessel or topical coagulation should be
Creation of the Posterior Cystgastrostomy attempted. If these maneuvers are not effective, packing
Inability to Locate the Cyst of the cavity and immediate angiographic embolization
The cyst can typically be felt by palpation or visualized of the bleeding vessel may be warranted.
owing to an impression on the posterior gastric wall.
Prevention
Consequence Great caution should be used when creating the
Creation of a gastrotomy not in continuity with the opening to perform this through an avascular plane
pseudocyst. in the mesocolon. Aspirating with a small-gauge
Grade 1 complication needle may provide some safety before making the
opening. One should avoid carrying the opening too
Repair medial to avoid injury to the middle colic vessels.
Closure of the aberrant opening and reassessment. Typically, the opening should be to the left of the
ligament of Treitz to avoid this complication.
Prevention
The cyst cavity can be detected by aspiration with a
22-gauge needle through the posterior gastric wall. Creation of the Roux-en-Y Cystjejunostomy
Alternatively, intraoperative ultrasound can be used to
Anastomotic Leak
localize the cyst.
Consequence
Undrained uid collection or abscess, sepsis.
Roux-en-Y Grade 1 complication

Cystjejunostomy Repair
Percutaneous drainage of the uid collection to try to
INDICATIONS create a controlled stula is paramount. If the uid is
amylase rich, the patient should be started on octreo-
Large, greater than 5 cm persistent pseudocyst. tide. Once the drain has been left for 6 weeks, a drain
study can be performed. If there is no collection, the
drain can be removed and the epithelialized tract will
OPERATIVE STEPS generally seal.

Step 1 Identication and opening of pseudocyst wall Prevention

through transverse mesocolon Closed-suction drains should be left above and below
Step 2 Creation of Roux-en-Y cystjejunostomy the anastomosis. These drains should be left in place
until there is certainty that no leak has occurred.
OPERATIVE PROCEDURE

Identication and Opening of the Pseudocyst

Wall through the Transverse Mesocolon
External Drainage
Inability to Locate the Cyst INDICATIONS
See the section on Inability to Locate the Cyst, under
Cystgastrostomy, earlier. Typically by lifting the trans- Infected pseudocyst or phlegmon.

OPERATIVE STEPS
Step 1 Identication and opening of pseudocyst wall
through transverse mesocolon
Step 2 Dbridement of necrotic or infected tissue
Step 3 Placement of large-bore sump drains
OPERATIVE PROCEDURE
Identication and Opening of the Pseudocyst
Wall through the Transverse Mesocolon
Same pitfalls as in the sections on Inability to Locate the
Cyst, and Injury to the Mesocolon Vessels, under
Roux-en-Y Cystjejunostomy, earlier.
Dbridement of Necrotic or Infected Tissue
The uid and tissue within the phlegmon is typically of
a semisolid consistency much like that of toothpaste. As
the rst step, the author prefers to manually dislodge
and remove this tissue through the opening created. The
tissue separates fairly easily from the underlying viable
pancreatic tissue. Russian forceps can then be used to
extricate the hard-to-reach areas. Irrigation with a red
rubber catheter can also be employed to remove dislodged
particles.
Pancreatic Bed Hemorrhage
Overaggressive dbridement can result in hemorrhage
from the pancreatic bed. Minor bleeding can occur from
surface branches. More substantial bleeding can occur
from the pancreatoduodenal vessels or dorsal pancreatic
vessels.
Consequence
Major hemorrhage during or after the procedure can
lead to disastrous consequences.
Grade 3 complication
Repair
When hemorrhage is recognized during the procedure,
suture ligation should be attempted. If this fails,
packing the opening and quickly transporting the
patient for angiographic embolization is the indicated
treatment.
Prevention
The necrotic tissue is generally of a different consis-
tency than the underlying parenchyma and should
elevate quite easily. Densely adherent tissue that does
not easily elevate with manual dbridement or irriga-
tion should be left behind.
38 PANCREATIC CYST/DEBRIDEMENT 385
Placement of Large-Bore Sump Drains
Large-bore sump drains should be placed in the pancreatic
bed and brought external. These drains should have an
opening of sufcient size such that particulate material can
be drained adequately. A drain in the style of a Waterman
sump is one variation. Alternatively, some surgeons use
stuffed Penrose drains as packing, with sequential removal
once they stop draining.
Surgical Management
of Pancreatic Necrosis
Patrick G. Jackson and Trevor Upham
INTRODUCTION
Pancreatic necrosis occurs as a sequela of approximately
15% to 30% of the 185,000 cases of acute pancreatitis in
the United States every year.1 Pancreatic necrosis exists as
a continuum from sterile pancreatic necrosis to infected
pancreatic necrosis (Fig. 381). Bacteria infect the sterile
necrotic pancreas, probably via translocation from the colon,
in a time-dependent manner from the onset of pancreatitis.
The infection rate of the sterile pancreatic bed ranges from
approximately 24% within 1 week to 71% within 3 weeks
in the absence of treatment.2 If untreated, infected pancre-
atic necrosis can progress to a dense walled-off collection
of pus and liqueed necrosis. To prevent the associated
systemic complications, early recognition of infection and
proper treatment, medically or surgically, are critical.
In the setting of known infected pancreatic necrosis or
worsening clinical presentation indicative of infection,
pancreatic dbridement is necessary to prevent the lethal
systemic inammatory response syndrome (SIRS) and
possible multiple organ system failure. Surgical treatment
of a necrotic pancreas requires careful approach, dbride-
ment, and postoperative management to resuscitate the
critical organ.
Surgeons select the appropriate surgical protocol from
the three primary methods that exist for surgical dbride-
ment and packing: (1) open dbridement with closed
packing, (2) open dbridement with closed lavage, and
(3) open dbridement with open packing.
Open dbridement consists of gentle blunt nger dis-
section to carefully identify all necrotic tissue and nger
abrasion with sponges covering the ngertips to remove
the necrotic tissue. Because the necrotic tissue may be very
poorly demarcated, a preoperative computed tomography
(CT) scan can be used as a guide to identify and dbride
all necrotic areas of the pancreas and any necrotic attach-
ment to local structures. Generous interoperative lavage
is encouraged.
 386 SECTION IV: HEPATOBILIARY SURGERY
Closed packing involves placement of -inch Penrose
drains or an Abramson drain in conjunction with several
Jackson-Pratt (JP) drains.
Closed lavage consists of placement of single- and
double-lumen catheters in the cavity. The drains on the
left traverse from the cavity posterior to the large bowel,
inferior to the spleen, and anterior to the kidney through
separate skin stab wounds. On the right, the drains tra-
verse from the cavity through the foramen of Winslow to
separate skin stab wounds. The gastrocolic ligament and
transverse mesocolon are closed with sutures to create a
conned space for concentrated lavage. Hyperosmolar
potassium-free dialysis uid is used postoperatively to
lavage the cavity at a rate of 2 L/hr until the efuent lacks
necrotic tissue and does not contain amylase.
Open packing involves an approach through a horizon-
tal incision. The cavity is packed with moist gauze. Red-
bridement with lavage is performed rst after 48 to 72
hours and then every 48 hours until the cavity is clean
with healthy granulation tissue at the base. The cavity is
then managed with surgical drains.
Choosing between these strategies must be done in the
scope of the clinical details of the necrotizing process as
well as the available surgical expertise and ancillary support
staff. In that all strategies have equivalent outcomes, the
choice of approach is largely surgeon dependent.
Regardless of the chosen surgical protocol, minimiz-
ing surgical complications while optimally preserving
the remaining pancreatic function proves a delicate task
that favors foresight to prevent surgical management
pitfalls. Although all operative strategies have equivalent
outcomes, open dbridement with close packing is
preferred.
To avoid the following pitfalls, carefully planned surgi-
cal management of pancreatic necrosis is mandated in the
setting of known infected pancreatic necrosis or worsen-
ing clinical presentation indicative of infection. Surgical
outcomes can be maximized with complete dbridement
Figure 381 Retroperitoneal air with infected necrosis.
of the necrotic tissue and management of the residual
cavity with carefully chosen closed packing, closed lavage,
or open packing.
INDICATIONS
Infected pancreatic necrosis
Worsening clinical symptomatology of infection in
setting of pancreatic necrosis
OPERATIVE STEPS
Step 1 Skin incision
Step 2 Entrance into lesser sac to expose pancreas
Step 3 Dbridement of necrotic pancreas
Step 4 Surgical drainage
Step 5 Closed packing
Step 6 Abdominal closure
Skin Incision
Delayed Pancreatic Dbridement
Consequence
SIRS and possible multiple organ system failure.
Grade 3/4 complication
Repair
Surgical dbridement.
Prevention
Surgical dbridement is indicated in the setting of (1)
infection, (2) increasing toxicity in the absence of infec-
tion, (3) failure to improve clinically despite continued
support over 3 to 4 weeks, or (4) an acute abdominal
catastrophe.3 A commonly used and helpful means of
identifying infection in pancreatic necrosis is the liberal
use of cross-sectional imaging, with the identication
of retroperitoneal gas from gas-forming bacteria.
Extensive studies have failed to dene a universally con-
crete time point to operate in the setting of sterile pan-
creatic necrosis. Sterile pancreatic necrosis requires careful
consideration for surgical dbridement on a case-by-case
basis. In the setting of true sterile pancreatic necrosis,
conservative management without surgery is warranted.
Patients must be closely monitored for signs of organ
failure or SIRS including tachycardia, tachypnea, leukocy-
tosis, fever, or hypoxia. Concurrently, imipenem/cilastin
may be used to reduce the progression to pancreatic
necrosis.4 Fluoroquinolones also provide broad coverage
and good pancreatic penetration. Cautionary use of anti-
biotics in this setting is advised because progression to
pancreatic infection by typical enteric pathogens may be
supplanted by fungal or gram-positive nosocomial infec-
tions.5 In addition to antibiotics, ne-needle aspiration
may be used, and repeated, whenever sterile necrosis is

Transverse Middle colic
mesocolon artery
Figure 382 Infra-mesocolic exposure of pancreatic bed.
clinically ambiguous. In the absence of retroperitoneal
gas, repeat CT imaging is an unreliable marker of pro-
gression to infection. In addition, repeat images are
advised when surgical dbridement would be seriously
consideredfollowing the second week after initial pan-
creatitis presentation, unless the clinical picture mandates
otherwise.
Again, the assumption of sterile pancreatic necrosis
must always be questioned. Surgical dbridement must
be considered in the setting of unresolving or signicant
new signs of SIRS that warrant surgical intervention.6,7 If
pancreatic necrosis is known to be infected, surgical inter-
vention is required.
If pancreatic necrosis has progressed to a well-
developed, uncomplicated true pancreatic abscess, primary
treatment with concurrent culture-sensitive antibiotics
and percutaneous drainage or endoscopic drainage of the
abscess cavity through the posterior wall of the stomach
may prevent surgical necessity. Before this treatment
is begun, the diagnosis of a true pancreatic abscess
must be questioned and obscured necrotizing processes
ruled out.
Entrance into the Lesser Sac to Expose
the Pancreas
Ligation of the Middle Colic Vessels
Consequence
Possible large bowel ischemia.
Grade 2/3/4 complication
Repair
Bowel resection.
Prevention
Surgical access to the lesser sac for surgical dbridement
of the pancreas can be approached via the gastrocolic
38 PANCREATIC CYST/DEBRIDEMENT 387
ligament or through the transverse mesocolon (Fig.
382). A local inammatory response often makes the
gastrocolic ligament access difcult enough to warrant
access via the mesocolon. The middle colic vessels must
be carefully identied to avoid ligation. If the middle
colic vessels are the sole blood supply to areas of the
colon, ligation of this sole blood supply will lead to an
ischemic bowel, requiring resection. Thus, access to the
lesser sac via the mesocolon should be carefully made
on either side, or on both sides, of the middle colic
vessels.1 Ligation of the middle colic vessels is reserved
only for necessary surgical access to the pancreas when
other approaches are not possible.
Dbridement of the Necrotic Pancreas
Damage to Peripancreatic Critical
Vascular Structures
Consequence
Operative blood loss secondary to inferior vena cava,
splenic, or portal vein damage.
Grade 3/4 complication
Repair
Surgical repair of the vasculature.
Prevention
Extensive necrotic involvement may attach to local
structures. Excessive dbridement may leave the portal
vein near the head of the pancreas and the splenic vein
near the tail of the pancreas vulnerable to avoidable
damage. Extensive retroperitoneal involvement may
compromise the structure of the vena cava. Although
demarcation of necrotic borders may not be present,
only semisolid necrotic tissue must be gently dbrided
without unnecessarily disrupting the vasculature.
Endocrine or Exocrine Insufciency
Consequence
Diabetes mellitus results from lack of endocrine func-
tion of the pancreas. Malabsorption, steatorrhea, and
associated abdominal symptomatology result from
insufcient exocrine secretions.
Grade 2 complication
Repair
Medical management of glucose control and supple-
mentation of pancreatic enzymes.
Prevention
Maximal preservation of healthy pancreatic endocrine
tissue is ideal. Exocrine and endocrine deciencies
do not result from dbridement because the majority
of dbrided tissue is peripancreatic inammatory soft
tissue, and dbridement removes only the already-
demarcated necrotic tissue, rather than viable pancreas.
 388 SECTION IV: HEPATOBILIARY SURGERY
Rather, exocrine and endocrine deciencies result from
the inammatory insult of necrotizing pancreatitis to
the islets of Langerhans and exocrine glands. In order
to maximize pancreatic function in the setting of nec-
rotizing pancreatitis, physicians must be diligent with
the treatment of sterile pancreatic necrosis and carefully
monitor for surgical indication.
Surgical Drainage
Pancreaticocutaneous Fistula
Consequence
Leakage of pancreatic amylase and proteins onto the
skin may induce inammatory mediators and potential
hypercholeraemic or normal anion gap metabolic
acidosis.
Grade 2/3 complication
Repair
Suppression of pancreatic enzymes with octreotide,
catheter manipulation or replacement, and possible sur-
gical correction.
Prevention
Recognition of patients with a high risk of pancreati-
cocutaneous stula formation and carefully coordinated
surgical drainage of the surgical cavity are the best
methods to avoid the occurrence and complications of
a pancreaticocutaneous stula.
The more severely the pancreatic parenchyma is dis-
rupted by disease, the more likely a pancreaticocutaneous
stula will occur. Consequently, severe pancreatitis and,
possibly, pancreatitis of biliary cause are most likely to
result in a pancreaticocutaneous stula.8
Percutaneous drainage, either used alone or postop-
eratively, must be monitored daily in critically ill patients
Jp
Jp
Jp
Jp
Figure 383 Extensive drainage of pancreatic infection.
in order to determine necessary (1) changes in nutrition
or antibiotic treatment, (2) catheter ushing, manipula-
tion, or replacement, and (3) indication for surgical
intervention.
Prophylactic octreotide9,10 may also be used when a
high likelihood of pancreaticocutaneous stula exists, such
as in severe pancreatitis.
Limited Surgical Drainage
Consequence
Persistent infection.
Grade 2/3/4 complication
Repair
Redbridement.
Prevention
The large residual cavity following pancreatic dbride-
ment must be carefully managed to prevent further
infection, visceral communication, and erosion of blood
vessels. The Penrose or Abramson drain must be
removed before JP drains to prevent pancreatic ascites
or a pancreatocutaneous stula (Fig. 383). If Penrose
drains are used, sequential removal, one drain per day,
7 to 10 days postoperatively, carefully allows the cavity
to collapse in a stepwise fashion.
Pancreatic Ascites and Pancreatic
Pleural Effusion
Consequence
Fistula formation and erosion of peripancreatic struc-
tures by exocrine secretions.
Grade 2/3/4 complication
Repair
Conservative treatment consists of gastrointestinal rest,
nasogastric suction, octreotide, and total parenteral
nutrition. Treatment of the stula is fostered by repeat
paracentesis and thoracocentesis as well as chest
tube drainage. Surgical intervention is indicated when
there is no clinical improvement from conservative
measures. Endoscopic placement of a pancreatic duct
stent may also be useful.
Prevention
Although clinical symptoms of pancreatic ascites and
effusions are very similar to those of other pancreatic
disease, any patient clinically suspected to have pancre-
atic ascites or pleural effusion should have the appropri-
ate bodily uids sampled for amylase and albumin via
paracentesis or thoracocentesis. If pancreatic ascites has
occurred, the amylase level will always be markedly
elevated (>1000 Somogyi units/100 ml), and in the
absence of hypoalbuminemia, the albumin level will be
greater than 3 g/100 ml. If conservative management

of the pancreatic ascites or pleural effusion fails to
reverse the course of disease, surgical correction is war-
ranted based upon the pancreatic duct anatomy and the
extent of damage from the ascites.11
Abdominal Closure
Intra-Abdominal Swelling with Challenging
Abdominal Wall Closure
Consequence
Dehiscence, wound infection, or abdominal hernia.
Grade 2/3 complication
Repair
Antibiotics. Possible surgical correction of the incision
or hernia.
Prevention
Two types of incisionshorizontal and verticalmay
be made to gain access to the pancreas. Horizontal
transverse or subcostal chevron incisions leave the
incision more difcult to approximate and often require
mesh fortication. The preferable vertical midline inci-
sion allows better approximation and rarely involves
mesh placement. Properly placed retention sutures are
used to best close the abdominal wall.
REFERENCES
1. Jackson PG, Rattner DW. Pancreatic abscess. In Cameron
JL (ed): Current Surgical Therapy, 7th ed. St. Louis:
Mosby, 2001; pp 539543.
38 PANCREATIC CYST/DEBRIDEMENT 389
2. Rau B, Pralle V, Uhl W, et al. Management of sterile
necrosis in instances of severe acute pancreatitis. J Am
Coll Surg 1995;181:279288.
3. Bouvet M, Moossa AR. Pancreatic abscess. In Cameron
JL (ed): Current Surgical Therapy, 8th ed. Philadelphia:
Mosby, 2004; pp 476479.
4. Bassi C, Falconi M, Talamini G, et al. Controlled clinical
trial of peroxacin versus imipenem in severe acute
pancreatitis. Gastroenterology 1998;115:1513
1517.
5. Buchler M, Malfertheiner P, Friess H, et al. Human
pancreatic tissue concentration of bactericidal antibiotics.
Gastroenterology 1992;103:19021908.
6. Buchler MW, Gloor B, Muller CA, et al. Acute necrotiz-
ing pancreatitis: treatment strategy according to the status
of infection. Ann Surg 2000;232:619626.
7. Warshaw AL. Pancreatic necrosis: to dbride or not to
dbride?That is the question. Ann Surg 2000;232:627
629.
8. Fotoohi M, DAgostino HB, Wollman B, et al. Persistent
pancreatocutaneous stula after percutaneous drainage of
pancreatic uid collections: role of cause and severity of
pancreatitis. Radiology 1999;213:573578.
9. Rosenberg L, MacNeil P, Turcotte L. Economic evalua-
tion of the use of octreotide for prevention of complica-
tions following pancreatic resection. J Gastrointest Surg
1999;3:225232.
10. Yeo CJ. Does prophylactic octreotide benet patients
undergoing elective pancreatic resection? J Gastrointest
Surg 1999;3:223224.
11. Kaman L, Behera A, Singh R, Katira RN. Internal
pancreatic stulas with pancreatic ascites and pancreatic
pleural effusions: recognition and management. Aust N Z
J Surg 2001;71:221225.
39
Resection and Reconstruction of
the Biliary Tract
David A. Bruno, MD and Thomas M. Fishbein, MD
INTRODUCTION
In 1891, in Dresden, Germany, Oskar Sprengel published
the rst report of a choledochoenterostomy. In this
patient, after a successful cholecystectomy, Dr. Sprengel
was unable to clear the distal common bile duct of stones.
A choledochotomy was made, and the common bile duct
was anastomosed to the duodenum. Although the rst
patient survived, subsequent attempts resulted in several
deaths, presumably from bile peritonitis followed by
sepsis.1,2 Not until a successful series of cases in the early
20th century was the operation accepted as standard of
care.3 Many years later, it was recognized that hepatic
ducts could also be resected and reconstructed with atten-
tion to two simple principles: The anastomosis must be
performed free of tension and with direct mucosal apposi-
tion to facilitate proper healing. These principles still
maintain today.
Safe and effective biliary reconstruction requires
intimate knowledge of normal anatomy as well as
commonly recognized variations in biliary and vascular
anatomy of the liver and porta hepatis. Proper exposure
allowing careful dissection in this region is of paramount
importance. Resection and reconstruction, performed
to establish biliary continuity with the small bowel, is
the usual goal, regardless of the specic pathology.
When malignancy is the indication for surgery, anatomic
planes are frequently altered owing to inammation,
desmoplastic reaction, and sometimes, tumor mass,
increasing the complexity of the procedure. All proce-
dures involving the biliary tract involve several operative
steps: exposure, dissection, and establishment of biliary
continuity.
INDICATIONS
Bile duct obstruction
Biliary injurytrauma
Biliary stula
OPERATIVE STEPS
Step 1 Incision
Step 2 Exposure of hepatoduodenal ligament
Step 3 Dissection of common bile duct
Step 4 Duct division
Step 5 Duct resection or closure
Step 6 Reestablishment of biliary continuity
OPERATIVE PROCEDURE
Resection and restoration of biliary continuity above or
below the hepatic bifurcation.
Operative Incision
This is reviewed in Section IV, Chapter 32, Right
Hepatectomy.
Briey, this can be optimally accomplished through a
right subcostal incision, a midline incision, or a bilateral
subcostal incision. Prior operations may dictate which of
these is chosen, whereas in patients with no prior opera-
tions, a right or bilateral subcostal incision is preferred.
Bile Duct Isolation
Extrahepatic Bile DuctBlood Supply
The blood supply to the extrahepatic bile duct is derived
from vessels on the medial and lateral walls of the duct,
sometimes referred to as 9 oclock and 3 oclock posi-
tion4 (Fig. 391). Blood ow derives both from intrahe-
patic arteriobiliary collateral circulation downward and
upward from the gastroduodenal artery.
Bleeding from Peribiliary Vessels
Consequence
Failure to avoid or ligate these vessels and adequately
control hemorrhage can lead to three possible compli-
cations. First, poor visualization may increase the
likelihood of injury to other vital structures, most
 392 SECTION IV: HEPATOBILIARY SURGERY
Right hepatic
artery
Common hepatic
artery
3 oclock vessels
9 oclock vessels
Common bile duct
Figure 391 Bile duct lateral vessels. Note the right hepatic
artery courses posterior to the common bile duct.
commonly, the right hepatic artery. Second, postop-
erative bleeding from the anastomosis may occur.
Third, injury and extensive coagulation may lead to
ischemia of the duct, leading to late stricture formation
at the anastomosis.
Grade 3 complication
Repair
Careful ligation of larger peribiliary vessels at the point
of transaction of the duct should be undertaken, usually
with ne monolament suture. Smaller vessels may be
controlled with electrocautery. Care must be taken
when using electrocautery because thermal damage to
the biliary tree may result in late stricture.5
Prevention
Preoperative understanding of the normal and variant
anatomy of the biliary tree and its surrounding vessels
is essential. In normal anatomy, the common bile duct
is derived from one left and one right hepatic duct
joining at the hepatic hilum. The right hepatic artery
branches from the proper hepatic artery medial to the
duct, giving off small branches to the bile duct. Addi-
tional branches may be derived from the right hepatic
artery lateral in the porta hepatis once it has passed
posterior to the duct. The right hepatic artery bifur-
cates into anterior and posterior sectoral branches
lateral to the duct. A replaced right hepatic artery
sometimes courses lateral to the portal vein and gives
off branches to the bile duct.
Common Hepatic Artery Injury
Consequence
Hepatic artery anatomy can sometimes be obscured by
pathology and variations in anatomy.612 As the duct is
dissected and prepared for division or resection, iden-
tication of the common hepatic artery origin should
be noted. Inadvertent injury to the hepatic artery will
result in brisk hemorrhage. Complete ligation and divi-
sion may result in ischemia of the right hepatic lobe of
the liver. This can result in hepatic parenchymal damage
postoperatively, sometimes leading to intrahepatic
biliary necrosis, biloma formation, or abscess.
Grade 3 complication
Repair
Incomplete transection of the proper hepatic artery
should immediately be recognized. Control of the
proximal and distal segments with vascular clamps
should immediately be obtained. The artery itself
should be repaired with an appropriately sized mono-
lament suture. Repair should be made in a transverse
fashion in order to avoid narrowing of the artery. If the
artery has suffered injury that makes a clean complete
primary repair impossible, the authors recommend
completing transection of the artery at the site of the
injury and direct end-to-end anastomosis.13,14
Prevention
Never transect the common bile duct until the hepatic
artery has been positively identied at the level of
planned transection. Encircle only the bile duct if
possible.
Proper Hepatic Artery Injury
Consequence
Variations in both the right and the left hepatic
arteries are common.15 Division of the proximal
common bile duct without identication of arterial
supply in the porta should be avoided (Fig. 392).
Early proper hepatic arterial injury can lead to hemor-
rhage and hepatic parenchymal ischemia. Unrecog-
nized division of these arteries has been associated with
strictures and the formation of bilomas late after
surgery.1618
Grade 4 complication
Repair
Inadvertent transection of the right or left hepatic artery
should be repaired with an end-to-end anastomosis
after proximal and distal control is established.1922
Nonabsorbable monolament sutures are appropriate
for repair. In the patient in whom an accessory hepatic
artery branch exists and either it or the proper branch
is injured, an injury of one may not require repair. The
proximal stump of the injured vessel may be examined
for backbleeding, which if it is judged to be pulsatile
and sufcient, implies adequate intraparenchymal col-
lateral circulation. Such an accessory branch may be
ligated. High injuries of right hepatic artery branches
may not allow distal control, thus requiring direct
suture repair or closure.
 39 RESECTION AND RECONSTRUCTION OF THE BILIARY TRACT
Figure 392 Replaced right hepatic artery. This usually runs
posterior to the portal vein, but may then course anteriorly to lie
just behind the bile duct above the cystic duct.
Prevention
Proper hepatic artery injury prevention begins with an
intimate knowledge of variations before entering the
operating room. Potentially hazardous variations of
hepatic artery anatomy include an early trifurcation
branching into (1) right and (2) left hepatic artery
branches and the (3) gastroduodenal artery low in the
porta hepatis, the right hepatic artery deriving from the
superior mesenteric artery posterior to the portal vein,
the right hepatic artery passing anterior to the common
bile duct, and the entire proper hepatic artery arising
from the gastroduodenal artery (Fig. 393).4 Early
identication of the proper hepatic artery by palpation
medial to the bile duct low in the porta hepatis is
advantageous.
Portal Vein Injury
Consequence
Inammatory reactions, secondary to benign or malig-
nant disease, may result in a proximal common bile
duct or hepatic ducts that are adherent to the portal
vein. These may occur in the setting of pancreatitis,
chronic biliary infections, biliary stula, and cholan-
giocarcinoma. Excessive dissection can cause disrup-
tion of the sometimes-attenuated anterior wall of
the portal vein. Hilar cholangiocarcinoma frequently
directly invades the vein or small portal branches, such
as branches draining the left caudate (Fig. 394). This
vascular invasion must be recognized to avoid injury.
Grade 3 complication
393
Figure 393 Right hepatic artery (RHA) is shown coursing ante-
rior to a fusiform choledochal cyst (CDC) and entering the hilum
anteriorly. Blue loop identies the common bile duct, which usually
is anterior to the RHA. CBD, common bile duct; CHA, common
hepatic artery; LHA, left hepatic artery.
Atrophic left lobe with no portal vein seen
Figure 394 Computed tomography (CT) scan shows hilar chol-
angiocarcinoma invading the left portal vein.
Repair
The portal vein can be manually compressed and then
occluded with a Pringle maneuver proximal to the dis-
ruption in order to allow sufcient exposure during
bleeding. A vascular clamp is then placed on the vein,
and primary repair with nonabsorbable monolament
suture can be undertaken.2325 The vein wall should be
directly visualized and transverse repair performed to
avoid narrowing the vein, which can lead to late portal
thrombosis. Freeing a length of the vein, when possible,
allows tension-free repair. This sometimes requires the
ligation of a small pancreatic branch on the right anterior
portal vein wall. Division of the gastroduodenal artery
allows easy visualization of the proximal portal vein.
Prevention
Recognition of a portal vein that is densely adherent to
the common bile duct is the rst step in prevention of
 394 SECTION IV: HEPATOBILIARY SURGERY
this injury. In such cases, circumferential control of the
bile duct may not be required. Instead, in the case of
benign disease or unresectable malignancy, the duct
may be incised anteriorly, leaving the adherent poste-
rior wall intact. Anastomosis to the intestine may be
accomplished safely by placing sutures into the intact
posterior wall after suturing the distal portion of the
duct closed. Alternatively, if the bile duct can be tran-
sected, minimal dissection proximally up to the liver
may be performed to allow suture placement without
injuring the anterior portal vein wall. Placing the pos-
terior wall sutures on the inside of the anastomosis
decreases the potential for injury in patients in whom
the duct is adherent to the portal vein.
Excision
Distal Stump Leak
Consequence
Failure to ligate the distal remnant of the common bile
duct in procedures that call for complete common bile
duct resection can result in a retrograde reux from the
duodenum. This may result in peritonitis and abscess
formation from reuxed enteric contents.
Grade 2 complication
Repair
This complication sometimes presents in the late post-
operative period. Endoscopic stent placement via endo-
scopic retrograde cholangiopancreatography (ERCP)
to decrease intrabiliary pressure and allow duodenal
drainage can result in closure of the leak.18,2630
Prevention
Closure of the distal ductal remnant with suture or
tying is critical to prevent this injury. One must ensure
that all lumens seen at the point of division of the duct
are closed adequately. Recognition of aberrant biliary
anatomy, including a low insertion of the right poste-
rior sectoral bile duct or an accessory right bile duct
running parallel to the common bile duct prior to
entry, may leave a lateral opening in the common bile
duct wall that may leak. A low insertion of the cystic
duct below the level of transection likewise may lead
to the same complication (Fig. 395).
Biliary Stricture
Consequence
Hepatic duct and common bile duct blood supplies run
axially along the length of the ducts (see Fig. 391).
Excessive dissection of the duct beyond the area of
excision may lead to ischemia, which in turn may lead
to either early bile leak or late stricture formation.31
Grade 2/3 complication
Repair
When anastomotic disruption due to ischemia, tension,
or late stricture occurs, two repair options exist. Early
LHA
RHA
Figure 395 Normal level of insertion of cystic duct (CD) and
cystic artery (CA) in Calots triangle. LHA, left hepatic artery; RHA,
right hepatic artery.
leak may be managed by early reoperation in the
absence of systemic sepsis and if diagnosed promptly.
Late diagnosis of leak may be best managed with con-
servative measures of drainage and delayed repair if
stricture ensues. Stricture late after anastomosis may be
managed utilizing decompression (transhepatic access
is usually preferable) and either balloon dilation or
denitive surgical repair.28,3235 In patients in whom
access cannot be obtained via the transhepatic approach,
a transjejunal approach can occasionally be used for
dilation of the stricture.3639
Prevention
Adequate blood supply at the point of transection of
the bile duct is critical to ensure prevention of compli-
cations. This is generally ensured by observation of
good bleeding from the cut edge of the transected
duct. This usually requires direct suture ligation of the
bleeding vessels. Dissection of the duct near the area
to be transected should be lateral to the ductal tissue,
leaving periadventitial tissue undisturbed. The area
should not be skeletonized in the manner of vascular
dissection. If there is any indication that the duct has
been devascularized, further resection to bleeding tissue
is required prior to anastomosis. Vessels running along
the duct should be directly ligated with ne monola-
ment suture.
Reconstruction and Reestablishment of
Biliary Continuity
Anastomotic Leak
Consequence
Irrespective of the method for reestablishing biliary
continuity, tension on the biliary-enteric anastomosis
may result in a bile leak. This may result in sterile
 39 RESECTION AND RECONSTRUCTION OF THE BILIARY TRACT
biloma, which can be drained, or uncontrolled
peritonitis.
Grade 2/3 complication
Repair
Anastomotic tension should be recognized immedi-
ately. A primary choledochocholedochostomy should
be performed only if the duct is freshly cut, with no
loss of bile duct length, as with a direct division during
another procedure. If duct edges are not cleanly divided
or there is any tension, a Roux-en-Y choledochojeju-
nostomy should be performed. A drain is generally
placed in the pouch of Morrison, the most dependent
portion of the abdomen, near the anastomosis. This
will usually control bile leakage if it occurs.
Prevention
Any sign of anastomotic tension will result in an anas-
tomosis that is prone to leakage. Such an anastomosis
should not be completed, with or without an internal
stent such as a T-tube. We recommend a Roux-en-Y
anastomosis that is retrocolic and approximately 40 cm
long. Mobilization of an adequate length of intestinal
mesentery will alleviate tension on the intestinal loop
utilized for anastomosis.
Hepatic Duct Leak
Consequence
Resections above the biliary bifurcation may result in
three or more hepatic ducts requiring reconstruction.
When a smaller stump is not recognized, it may not be
included in the hepaticojejunostomy. In this case, bile
will freely drain into the peritoneum and a biliary leak
will occur. As previously discussed, uncontrolled biliary
stula will result in bile peritonitis.
Grade 3 complication
Repair
Early recognition of all proximal extrahepatic ducts and
subsequent inclusion into the anastomosis will prevent
this complication. Smaller ducts such as those draining
the caudate lobe can be oversewn without loss of sig-
nicant hepatic parenchymal function. Those draining
larger areas of functional liver, such as anterior and
posterior sectoral ducts, may be joined together using
an intact back wall to provide a single larger anastomo-
sis. Repair of a missed duct postoperatively usually
requires reoperation and revision with construction of
an additional anastomosis.
Prevention
Preoperative imaging of the biliary tree above the site
of resection helps to prevent this by identifying the
intrahepatic anatomy. This is best accomplished with
percutaneous transhepatic cholangiography for totally
obstructing lesions but may sometimes be accomplished
395
Figure 396 Completed hepaticojejunostomy with an aberrant
right hepatic artery anterior to a Roux-en-Y loop of jejunum per-
formed tension free with mucosal apposition.
with imaging from below in cases in which dye will pass
through the area requiring repair. Magnetic resonance
cholangiography is increasingly used for this purpose.
Cholangiitis should be prevented by treating with sys-
temic antibiotics during these imaging studies, and
imaging from below should be accompanied by a drain-
age procedure (stent placement). Intraoperative recog-
nition of each duct transected as identied by imaging
will help prevent this complication. One must also rec-
ognize that little bile may be produced by liver seg-
ments that have been chronically obstructed at the time
of transaction, later to be followed by improved bile
ow after surgery. Thus, orices encountered that
appear consistent with biliary radicals should be tagged
and reconstructed despite the lack of good bile ow
intraoperatively. Probing what appear to be very small
ducts with a lacrimal probe will often demonstrate
direct access into a major lobe of the liver, making clear
the requirement for drainage (Fig. 396).
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4. Northover JM, Terblanche J. A new look at the arterial
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5. Hochstadetr H, Bekavac-Beslin M, Doko M, et al.
Functional liver damage during laparoscopic cholecystec-
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6. Abdullah SS, Mabrut JY, Garbit V, et al. Anatomical
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8. Chen CY, Lee RC, Tseng HS, et al. Normal and variant
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9. Koops A, Wojciechowski B, Broering DC, et al. Anatomic
variations of the hepatic arteries in 604 selective celiac
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10. Mlakar B, Gadzijev E, Ravnik D, et al. Anatomical
variations of the arterial pattern in the left hemiliver. Eur J
Morphol 2002;40:115120.
11. Mlakar B, Gadzijev EM, Ravnik D, Hribernik M.
Anatomical variations of the arterial pattern in the right
hemiliver. Eur J Morphol 2002;40:267273.
12. Mlakar B, Gadzijev EM, Ravnik D, Hribernik M.
Congruence between the courses of the biliary ductal and
the hepatic arterial systems. Eur J Morphol 2005;42:135
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13. Mathisen O, Soreide O, Bergan A. Laparoscopic cholecys-
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14. Doctor N, Dooley JS, Dick R, et al. Multidisciplinary
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15. Hiatt JR, Gabbay J, Busuttil RW. Surgical anatomy of the
hepatic arteries in 1000 cases. Ann Surg 1994;220:5052.
16. Krotovskii GS, Shcherbiuk AN, Gerasimov VB. [Intraop-
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17. Sankot J. [Injury of the hepatic artery]. Rozhl Chir 1998;
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18. Gupta N, Solomon H, Fairchild R, Kaminski DL.
Management and outcome of patients with combined bile
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19. Schmidt SC, Langrehr JM, Raakow R, et al. Right hepatic
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20. Schmidt SC, Langrehr JM, Settmacher U, Neuhaus P.
[Surgical treatment of bile duct injuries following laparo-
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Section V
ENDOCRINE SURGERY
Gerard M. Doherty, MD
A life spent making mistakes is not only more honorable but more useful than a life
spent doing nothing.George Bernard Shaw

40
Thyroid Surgery
Michael McLeod, MD and Gerard M. Doherty, MD

INTRODUCTION Local symptoms due to mass effects of enlarged

gland
Thyroid operations are usually safe procedures with rare
life-threatening complications. Complications common to
any operation, such as bleeding, infection, and anesthetic
reactions, are all quite unusual. Almost never is sufcient OPERATIVE STEPS (UNILATERAL
blood lost during the operation to require transfusion. LOBECTOMY)
After the procedure, bleeding can cause dangerous local
effects but only rarely requires blood replacement. The Step 1
neck is a privileged site for wound healing that can with-
stand substantial contamination without clinical infection. Step 2
These procedures are typically performed as ambulatory
or overnight hospitalizations, with short (13 hr) general
or regional anesthetic techniques, which limit the risk of Step 3
anesthetic or pulmonary complications and deep venous
thrombotic events. Step 4
However, thyroid surgery is considered a delicate area
of clinical practice. Signicant technical complications can
occur that can create permanent changes for the patient. Step 5
The most common of these are hypoparathyroidism and Step 6
nerve injury. Other less-frequent complications include
cervical hematoma and aerodigestive tract damage. Step 7
INDICATIONS
Step 8
Hyperthyroidism
Malignancy or suspicion of malignancy
Induce general anesthesia and secure
airway
Transverse incision along skin lines inferior to
thyroid isthmus through platymus, raising sub-
platysmal aps
Separate strap muscles in midline, exposing
thyroid gland
Expose upper pole vessels by dissecting between
cricothyroid muscle and thyroid gland and lateral
to thyroid gland
Divide upper pole vessels
Reect thyroid medially and dissect lateral aspect
of gland
Identify inferior thyroid artery, recurrent laryn-
geal nerves (RLNs), and parathyroid glands in
tracheoesophageal groove
Divide inferior thyroid artery branches, thyroid
attachment to trachea anterior to RLN inser-
tion, and inferior pole vessels
 398 SECTION V: ENDOCRINE SURGERY

Step 9 Divide thyroid isthmus. For bilateral procedures, Compression of the trachea can cause loss of airway
isthmus is usually left intact, and same steps are patency in the supine patient under anesthesia. Once
followed for contralateral lobe the negative intrathoracic pressure needed to lift the
Step 10 Obtain hemostasis and close wound in layers thyroid and keep the trachea patent is lost, it may be
difcult or impossible to ventilate the patient with
OPERATIVE PROCEDURE positive pressure. This can be avoided by using awake
intubation to maintain airway patency.
The potential complications of thyroid operations include Grade 2/3 complication
the immediate complication of cervical hematoma, as well
as the more chronic complications of hypoparathyroidism, Prevention
nerve injury, and injuries to the aerodigestive tract. Finally, Compression of the trachea in the neck can narrow the
chronic problems can arise from iatrogenic hyper- or lumen substantially and require placement of a smaller
hypothyroidism. endotracheal tube at intubation. However, the more
difcult management issue can be signicant lateral
deviation of the trachea. Although these patients can
Securing the Airway
usually be ventilated by positive-pressure mask ventila-
At the outset of the operation, for most patients, general tion, the shift of the larynx can make it difcult or
anesthesia is induced and an endotracheal tube is placed. impossible to access the vocal cords for placement of
For most patients, this is a routine and uneventful portion an endotracheal tube. Intubation over a beroptic
of the procedure; however, this can be the most danger- laryngobronchoscope can be helpful in most patients.
ous portion of the procedure for a patient with a large However, some patients cannot be intubated in spite
goiter or tumor (Fig. 401). of all attempts, who require tracheostomy at the outset
of the thyroidectomy in order to safely perform the
operation. Anticipation of the difculties that may be
Airway Management
faced, the assembly of a team expert in airway manage-
Consequence ment, and the readiness of an experienced surgeon
Because the thyroid lies directly anterior to the trachea, prepared to access the airway operatively are critical to
enlargement of the thyroid or direct invasion of the the safe outcome of these occasionally extremely chal-
trachea by tumor can cause airway compromise that can lenging and dangerous situations.
become critical during the induction of anesthesia.14
Dissection and Identication of
Cervical Structures
78 mm
After exposure of the thyroid gland (Fig. 402), the upper
pole vessels are divided (Fig. 403). The thyroid lobe is

45 mm

Thyroid Trachea

Upper pole

Left thyroid
lobe

Figure 401 Tomographic reconstruction of a substernal goiter

with airway compromise. The compression and shift of the trachea
in patients such as this can be particularly dangerous during the
induction of anesthesia. Intubation can be difcult, and the airway Figure 402 Exposure of the left lobe of the thyroid gland. The
can be lost with induction. sternohyoid and sternothyroid muscles are held by the retractor.

Upper pole
vessels
Figure 403 Division of the left upper pole vessels. These vessels
can be divided using a number of techniques, including division
between ligatures or clips or using powered hemostasis equipment,
as illustrated here.
Left upper
parathyroid
Thyroid lobe
Recurrent
laryngeal
nerve
Nerve stimulator
probe
Figure 404 Demonstration of the tracheoesophageal groove
dissection. The nerve is carefully exposed and may be conrmed
using intraoperative nerve monitoring, as demonstrated here. The
upper parathyroid is typically posterior to the recurrent nerve
position and superior to the inferior artery, as in this patient.
reected anteriorly in order to expose the tracheoesopha-
geal groove (Fig. 404). The dissection is carried down
along the medial surface of the carotid artery to the pre-
vertebral fascia. The inferior thyroid artery can be identi-
ed passing deep to the carotid in its course toward the
40 THYROID SURGERY 399
Upper
parathyroid
gland
Ligament of Berry
Recurrent
Left thyroid laryngeal
lobe nerve
Figure 405 The posterior attachment of the thyroid to the
trachea anterior to the recurrent laryngeal nerve (ligament of
Berry) is divided with careful avoidance of the recurrent nerve.
lower pole of the thyroid. Careful dissection is performed
around the inferior thyroid artery to identify the RLN as
it passes underneath or, less commonly, anterior to the
artery. If the RLN is not visible, it can usually be identied
caudally (in previously undissected areas) as it ascends in
the tracheoesophageal groove. The cephalad course of the
nerve is dened, taking care to preserve branches that arise
proximal to its disappearance under the caudal border of
the cricothyroid muscle. The right RLN arises more later-
ally in the chest than the left, leading to a more oblique
course.
The superior and inferior parathyroid glands may be
preserved by dissecting them away from the posterior
capsule of the thyroid gland with their vascular pedicles.
The superior glands are most commonly located on the
dorsal surface of the thyroid lobe at the level of the upper
two thirds of the gland (see Fig. 404). Although their
location is more variable, the lower glands usually lie
caudal to the inferior thyroid artery.
With the course of the RLN directly visualized, the
branches of the inferior thyroid artery are divided adjacent
to their entrance into the thyroid gland to preserve the
parathyroid blood supply. The inferior pole is then dis-
sected. A variable number of inferior thyroid veins and, in
some cases, a thyroid ima artery are divided. The RLN is
also vulnerable to injury in this area. With its upper and
lower poles free, the thyroid lobe remains xed to the
trachea by the ligament of Berry. The thyroid gland is
rolled medially, and with the RLN separated from the
thyroid gland and in clear view, the ligament is encircled,
ligated, and divided (Figs. 405 and 406).
During this active dissection, most complications of
thyroidectomy can occur.
 400 SECTION V: ENDOCRINE SURGERY
Cricothyroid
muscle
Ligament of Left upper
Berry ligature parathyroid
Thyroid
isthmus gland
Left thyroid
lobe
Recurrent
laryngeal
Trachea nerve
Figure 406 Completed dissection of the left lobe of the thyroid
gland. With the ligament of Berry divided, the thyroid lobe is
attached only by the isthmus, and the trachea returns to its natural
position. Careful hemostasis must be ensured.
Hypoparathyroidism
Consequence
The parathyroid glands are delicate structures that
share a blood supply with the thyroid gland. Their
diminutive size (normally 3060 mg) and fragile nature
make them particularly prone to damage during thy-
roidectomy. Patients who have markedly diminished or
absent parathyroid function after thyroidectomy have
severe hypocalcemia that requires replacement. If per-
manent, this complication can be palliated by calcium
and vitamin D supplements, but this requires multiple
doses each day, and uncomfortable symptoms occur if
doses are late or missed. In addition, there is cumula-
tive bone damage over time.
The symptoms of hypoparathyroidism are those of
severe hypocalcemia. Patients have numbness and tingling
in the distal extremities and around the mouth or tongue
in the earliest phases. With more severe hypocalcemia,
patients develop muscle cramping at rest or, especially,
with use. The anxiety that often accompanies these symp-
toms exacerbates them because the patient hyperventi-
lates. The consequent respiratory alkalosis shifts more
calcium intracellularly, lowering the serum level of calcium
and worsening the symptoms. Severe tetany can result.
Patients can then be limited in their ability to help them-
selves resolve the episode with calcium supplements
because their hands and forearms are often severely affected
by the muscle spasms.
The classic signs of hypocalcemia are Chvosteks sign
and Trousseaus sign. Chvosteks sign is generated by
tapping gently over the facial nerve in the lateral cheek to
demonstrate facial muscle contraction due to increased
nerve irritability. This sign is present in a minority of
people with a normal serum level of calcium and so is
not entirely reliable in the diagnosis of hypocalcemia.
Trousseaus sign is elicited by placing a sphygmomanom-
eter cuff on the upper arm and inating to systolic pres-
sure. Within a few minutes, the patient develops severe
carpal spasm, with exion of the wrist and ngers, and
abduction of the thumb. This sign is very uncomfortable
for the patient and should not be used clinically. In
general, the symptoms of hypocalcemia are much more
reliable and useful than the signs for patient assessment.
Grade 1/2 complication
Repair
The acute management of hypocalcemia in the postop-
erative patient depends upon the severity of the hypo-
calcemia and symptoms. Total serum calcium levels
correlate roughly with symptoms but are quite variable
between individuals. Some patients can have extremely
low total serum levels of calcium with no symptoms,
whereas others can have severe symptoms and signs,
with nearly normal calcium levels. Ionized calcium
measurements correlate better than total serum calcium
levels, but there is still variability. Replacement is gen-
erally guided by symptoms. For mild hypocalcemia
with tingling, oral calcium supplements (calcium car-
bonate, 5001500 mg by mouth, two to four times a
day) are often sufcient to resolve the hypocalcemia.
Daily doses of calcium above 3000 mg provide little
incremental benet, however, because of the limits of
gastrointestinal absorption of calcium. If supplementa-
tion beyond this level is necessary, the addition of
supplemental vitamin D (calcitriol 0.251.0 mcg daily)
will increase the gastrointestinal absorption of calcium.
Vitamin D requires 48 to 72 hours to have its effect,
however, so intravenous calcium supplementation may
be needed until then. Anticipation of the need for
vitamin D can smooth patient management consider-
ably by starting it early.
Hypocalcemia not controlled by oral supplements, or
accompanied by severe symptoms such as muscle cramp-
ing, is best managed by intravenous calcium administra-
tion. Intravenous calcium gluconate is the only option
for calcium supplementation. Calcium chloride can cause
severe tissue damage if accidental tissue inltration occurs
and should be used only for the acute, life-threatening
cardiac emergency. Bolus administration of calcium glu-
conate (supplied in 1000-mg ampules containing 90 mEq
calcium) corrects serum levels of calcium rapidly and
safely, although the effect is short lived. A preferable alter-
native is to use a calcium gluconate solution (6 ampules
calcium gluconate = 6 g calcium gluconate = 540 mEq
calcium in 500 ml D5W) infused at 1 ml/kg/hr. This
provides a steady calcium supplement and can be adjusted
to maintain the calcium in the normal range while oral
supplements are absorbed.
Temporary hypocalcemia occurs in about 10% of patients
after total thyroidectomy, and permanent hypocalcemia
occurs in about 1% (Table 401).511 The temporary hypo-
calcemia can be severe and requires intravenous and oral
 40 THYROID SURGERY 401

Table 401 Incidence of Complications after Total Thyroidectomy

Authors, Yr
Thompson, Farrar, Schroder, Clark, Ley, Tartaglia, Rosato,
19786 19805 19867 19888 19939 200310 200411

No. of Patients 165 29 56 160 124 1636 9599

Transient nerve paresis, N (%) NR NR 1 (2%) 4 (2.5%) 1 (0.8%) 31 (1.9%) 195 (2%)

Permanent nerve paresis, N (%) 0 1 (3%) 0 3 (2%)* 1 (0.8%) 15 (0.9%) 94 (1%)

Transient hypoparathyroidism, N (%) NR 2 (7%) 9 (17%) NR 13 (10%) NR 797 (8.3%)

Permanent hypoparathyroidism, N (%) <2% 4 (14%) 3 (6%) 1 (0.6%) 2 (1.6%) 14 (0.9%) 163 (1.7%)

*Each from deliberate sacrice of the recurrent laryngeal nerve due to tumor involvement.
NR, not reported.

supplementation for the duration of the effect. Permanent
hypoparathyroidism requires life-long support with calcium
supplements and vitamin D analogues. Missing doses of
the supplements will usually produce symptoms of varying
severity, and which, although manageable, are often quite
bothersome for patients. In addition to the discomfort and
inconvenience of the supplements, patients develop low-
turnover bone disease, which resembles osteomalacia.
Although dysmorphic, bone mass is generally preserved or
increased in hypoparathyroidism, and fracture risk is not
apparently increased. Finally, the calcium and vitamin D
supplements with low parathyroid hormone (PTH) lead
to an increased daily urinary excretion of calcium and
signicant risk of nephrolithiasis.
The recent availability of pharmacologic PTH for exog-
enous administration has opened the opportunity to
replace PTH in patients with postoperative hypoparathy-
roidism. The experience with this to date is limited, but
early results demonstrate that PTH delivered subcutane-
ously twice daily can maintain serum calcium levels in the
same range as oral calcium and vitamin D supplements
and decreases the amount of hypercalciuria.12 Further
experience with this strategy will be necessary before the
full long-term effects are clear.
Prevention
Avoidance of permanent hypoparathyroidism is far
more desirable than its treatment. This can be accom-
plished by preservation of the parathyroid glands on
their native blood supply or autografting of parathyroid
tissue to a muscular bed.13 During thyroidectomy,
the blood supply to each parathyroid gland should be
identied and specically considered during dissection.
Every parathyroid gland should be treated as though it
were the only remaining gland. The parathyroid glands
receive their blood supply via the inferior thyroid artery.
During dissection of the thyroid, the inferior thyroid
artery branches should be divided distal to the branch-
ing of the parathyroid end-arteries. The parathyroid
glands can then be moved posteriorly in the neck away
from the thyroid to allow safe dissection of the RLN
and thyroid attachments to the trachea.
If the parathyroid glands cannot be preserved on their
native blood supply, transfer of the gland to a convenient
grafting site can maintain function.13,14 For normal para-
thyroid glands, transfer to the sternocleidomastoid muscle
provides a convenient vascular bed for transplant. The
parathyroid gland must be reduced to pieces that can
survive on the diffusion of nutrients temporarily while
neovascular in-growth occurs over several weeks. This
strategy is effective, as is clear from operative series in
which all parathyroid glands were autografted in order to
try to optimize the long-term outcome of normal para-
thyroid function. All patients became temporarily hypo-
parathyroid, but all recovered to become dependent fully
on their autografts. Although this strategy is effective, it
leads to signicant short-term morbidity owing to the
uniform, severe hypocalcemia that occurs before graft
function begins. A selective strategy of autografting only
the parathyroid glands that are devascularized during dis-
section is equally effective and more comfortable for the
majority of the patients.
Nerve Injuries
Several nerves adjacent to the thyroid gland can be delib-
erately or inadvertently affected during thyroidectomy.
These include the RLN immediately adjacent to the
thyroid and the vagus nerve, which is slightly more
removed but causes the same symptoms when damaged.
The external branch of the superior laryngeal nerve can
be injured during dissection of the upper pole of the
thyroid gland, and the sympathetic chain and stellate gan-
glion can be injured near the posterior aspect of the upper
pole of the gland as well.
Recurrent Laryngeal Nerve
Consequence
The RLN bers are a part of the vagus nerve on each
side, until they branch off in the upper chest, course
around the ligamentum arteriosum (left RLN) or the
subclavian artery (right RLN), and back along the tra-
cheoesophageal groove on each side. They pass between
the thyroid and the larynx and insert in the larynx at
 402 SECTION V: ENDOCRINE SURGERY
the inferior border of the cricopharyngeal muscle. The
nerve often branches at about the level of the lower
pole of the thyroid and inserts to the larynx as two or
more adjacent bers. There is also an esophageal branch
that extends posteriorly from about the level of the
thyroid lower pole.
Damage to the RLN causes unilateral paralysis of
the muscles that control ipsilateral vocal cord tension.
Unilateral RLN injury changes the voice substantially in
most patients and also signicantly affects the swallowing
mechanism. The voice can range from a soft, whispery
voice, with the inability to increase the volume at all, to
a nearly normal-sounding voice, which cannot be raised
to a yell. The difference between these is based on the
ability of the contralateral vocal cord to cross the midline
and appose the affected cord. If the cords cannot meet,
the voice will be soft and breathy. If the cords can meet,
the speaking voice will be more normal in timbre, but the
affected cord prolapses with increased airway pressure and
the ability to yell is lost. Swallowing is affected also, and
the aspiration of liquids is a mark of severe RLN paresis.
This improves with time and can be helped by swallowing
training.
Bilateral RLN injury causes paralysis of both cords and
usually results in a very limited airway lumen at the cords.
These patients usually have a normal-sounding speaking
voice but severe limitations on inhalation velocity because
of upper airway obstruction. They often require reintuba-
tion to maintain ventilation.
Grade 2/3 complication
Repair
RLN paresis is usually temporary and resolves over days
to months (see Table 401).511 There is no known
method of aiding or speeding recovery. If a unilateral
paresis proves to be permanent, palliation of the cord
immobility and voice changes can be achieved with
vocal cord injection or laryngoplasty. These procedures
stiffen and medialize the paralyzed cord in order to
allow the contralateral cord to appose the paralyzed
cord during speech. If both cords are affected, the pal-
liative procedures are more limited and involve creating
an adequate airway for ventilation. Improvements in
voice quality are not likely because there is no muscu-
lar control of the cord function.
Prevention
Avoidance of RLN injury is far superior to palliation.
Great care must be taken during the dissection of the
nerve in order to protect it. In some clinical situations,
the RLN is sacriced in order to allow an adequate
tumor resection. Absent this unusual circumstance,
though, careful dissection can generally preserve cord
function. The principles of the dissection are
1. Avoid dividing any structures in the tracheoesopha-
geal groove until the nerve is denitively identied.
Small branches of the inferior thyroid artery may seem
like they can clearly be safely transected; however, the
distortion of tumor, retraction, or previous scar may
lead the surgeon to mistakenly divide a branch of the
RLN. The identifying feature of the RLN is that the
more it is dissected, the more it looks like the correct
structure. This is based upon the morphologic appear-
ance and the anatomic course. The nerve can tolerate
manipulation but not cutting. Once cut, repair of the
nerve is of unproven benet.
2. Identify the nerve low in the neck, well below
the inferior thyroid artery, at the level of, or below,
the lower pole of the thyroid gland. This allows dis-
section of the nerve at a site where it is not tethered
by its attachments to the larynx or its relation to the
inferior thyroid artery. Traction injuries to the nerve
can occur when the nerve is manipulated near a site of
xation.
3. Keep the nerve in view during the subsequent dis-
section of the thyroid from the larynx. Once the
nerve is identied, the dissection can generally pro-
ceed from inferior to superior along the nerve, dividing
the inferior thyroid artery branches and preserving the
parathyroid glands. This allows careful dissection of the
tissues with minimal manipulation of the RLN.
4. Minimize the use of powered dissection posterior
to the thyroid. Although the electrocautery and high-
frequency ultrasonic scalpel are useful tools in dissec-
tion, they have some risk of lateral thermal spread,
which can damage adjacent tissues. Careful cold dis-
section and hemostasis with ligatures or clips will avoid
this risk. This is particularly important at the entry of
the RLN to the larynx, immediately adjacent to the
ligament of Berry and its vessels.
The use of nerve stimulators and laryngeal muscle
potential monitors has been investigated as a tool to try
to limit or avoid nerve injuries.15,16 The data do not
currently support the routine use of these devices as
reducing the rate of RLN injury. This may be because they
help to identify the nerve, whereas the portion of the
operation most likely to produce damage in experienced
hands is the dissection of the RLN at the xed point
of the cricopharyngeus. Further investigation may iden-
tify specic circumstances in which this technology is
helpful.
About 10% of patients have some evidence of RLN
paresis after thyroidectomy; however, this resolves in most
patients. About 1% or fewer patients have permanent
nerve injury when total thyroidectomy is performed by
experienced surgeons (see Table 401).
External Branch of the Superior Laryngeal Nerve
Consequence
This nerve courses adjacent to the superior pole vessels
of the thyroid gland, before separating to penetrate the

cricopharyngeus muscle fascia at its superoposterior
aspect. The nerve supplies motor innervation of the
inferior constrictor muscles of the larynx. Damage to
this nerve changes the ability of the larynx to control
high-pressure phonation, such as high-pitched singing
(soprano/falsetto) or yelling.11,17
Grade 1/2 complication
Prevention
To avoid damaging this nerve, the dissection of
the upper pole vessels should proceed from a space at
which the nerve is safely sequestered under the crico-
pharyngeal fascia to the superior vessels themselves,
thus safely separating the nerve from the tissue to be
divided.
Sympathetic Chain
Consequence
Although it is separated from the posterior aspect of
the thyroid, the sympathetic chain and stellate ganglion
can be damaged during thyroidectomy, producing
Horners syndrome (ipsilateral ptosis, miosis, and anhi-
drosis). This is probably due to retractor-induced injury
because the sympathetic chain and ganglion itself are
out of the operative eld. These injuries are nearly
always temporary.
Grade 1/2 complication
Prevention
Avoid traction on the nerve.
Injury to Other Cervical Structures
Thoracic Duct
Consequences
The thoracic duct empties into the left internal jugular
vein, posterior to the clavicular insertion of the sterno-
cleidomastoid muscle. Damage to the thoracic duct can
cause a large collection of lymph or chyle in the oper-
ative bed.
Grade 13 complication
Repair
This can heal spontaneously after drainage if the leak
is small. However, frequently the leak continues in spite
of attempts to allow healing by decreasing output (a
fat-free diet or total dietary abstention, total parenteral
nutrition, and octreotide injections). If the leak persists
for more than 3 weeks, the thoracic duct can be divided
in the left hemithorax using thoracoscopic techniques.
This will nearly always allow the leak to heal.
Prevention
Identication of the duct can avoid injury. Identica-
tion of a leak intraoperatively allows obliteration of the
leak at that time to avoid postoperative leak.
40 THYROID SURGERY 403
Trachea
Consequences
Tracheal injuries can occur, particularly during removal
of large invasive tumors. Untreated injuries can result
in wound infection and tracheocutaneous stula.
Grade 13 complication
Repair
Most tracheal injuries can be repaired primarily with
resorbable suture. For defects larger than 10 mm, it
may be preferable to patch the trachea with a pedicle
of the sternocleidomastoid muscle or to perform a
sleeve resection of the affected area. If resected, the cut
ends of the trachea are reapproximated with absorbable
suture. A drain should be placed to evacuate any air
that escapes through the repair. This is less of an issue
if the patient is extubated at the completion of the
operation, avoiding the effects of positive-pressure ven-
tilation on the repair. A tracheostomy is rarely neces-
sary, although if there are other issues concerning
airway safety, placement of a temporary tracheostomy
may be preferable to prolonged intubation.
Prevention
Avoid injury to the trachea by careful dissection or
planned resection.
Esophagus
Consequence
Esophageal injuries rarely occur during thyroidectomy.
Untreated injury can result in deep space wound infec-
tion and esophageal-cutaneous stula.
Grade 24 complication
Repair
If the esophageal lumen is entered, the operative
options include primary repair or closure of the distal
lumen and construction of a cervical esophagostomy.
Primary repair is generally preferable, unless there is
extensive tissue loss or damage.
Prevention
Avoid injury to the esophagus via careful dissection or
planned resection.
Obtain Hemostasis and Close in Layers
After the completion of the central neck procedure, the
operative bed must be carefully inspected for hemostasis.
In particular, the area immediately anterior to the RLN
insertion under the inferior border of the cricothyroid
muscle is a site of frequent residual bleeding. This is the
site of the ligament of Berry division (see Figs. 405 and
406). Careful management of these bleeding sites is nec-
essary to ensure hemostasis without damaging structures
preserved during the dissection.
 404 SECTION V: ENDOCRINE SURGERY
Neck Hematoma
Consequences
A neck hematoma requiring reoperation develops after
operation in about 1 of every 150 thyroidectomies.18,19
The hematoma nearly always appears within the initial
6 hours after the completion of the procedure, although
with therapeutic anticoagulation, the hematoma can
appear up to several days later. This complication
is manifest by increasing pain, neck swelling, and
often marked anxiety. The hematoma can collect either
between the platysma muscle and the sternohyoid
muscles (supercial) or deep to the strap muscles along
the larynx (deep). The deep hematomas are the more
dangerous because they can be sequestered on one side
of the larynx, causing a shift and compression of the
airway.
Grade 15 complication
Repair
Although a minority of patients with postoperative
hematomas develop airway compromise requiring
emergent evacuation at the bedside, this possibility
exists with every neck hematoma. Patients with a hema-
toma of the neck should not be left alone until the
hematoma has been evacuated. Medical personnel with
the capability of opening the wound to decompress the
airway must stay with the patient until the situation is
resolved. For most patients, the hematoma is less
immediately threatening, and the patient can be
urgently returned to the operating room, placed under
anesthesia, and the hematoma evacuated and bleeding
controlled. Often, no specic bleeding site can be iden-
tied at reoperation, although when one is found, the
most likely areas are the anterior jugular veins under
the platysma aps, the superior pole vascular pedicle,
and the vessels of the ligament of Berry, adjacent to the
RLN insertion. The risk of cervical hematoma has led
some to question the safety of outpatient thyroidec-
tomy because there would be some possibility of the
hematoma developing after discharge.18,19 The current
experience with outpatient thyroid surgery by experts
in the eld has demonstrated that this can be done
safely, although postoperative observation for 6 hours
is routine in order to detect this complication prior to
facility discharge.
Prevention
Careful hemostasis during the initial operation is
required, with particular attention to these areas, to try
to prevent this complication.
Postoperative Thyroid Hormone Management
Iatrogenic Hyperthyroidism or Hypothyroidism
Consequences
After total thyroidectomy, and as a part of the therapy
for most thyroid carcinomas, patients receive thyroid
hormone replacement therapy.20 As a chronic medica-
tion, thyroid hormone is among the most well toler-
ated. It has a long half-life, which makes daily dosing
adequate and means that patients do not develop symp-
toms if they miss or change the timing of doses.
The problems with thyroid hormone administration,
however, are (1) its long half-life allows adjustment of
dosage only once per month or so, making the titration
of the proper dose a slow process; (2) its narrow ther-
apeutic window means that small changes in dosing or
medication preparation can change the physiologic
effect; and (3) it is largely protein-bound so other
protein-bound drugs or changes in the proteins them-
selves can change the effects of a given dose of the
drug.
Grade 1/2 complication
Prevention
Patients must understand that the process of titration
can take time. Trying to speed the process by making
more frequent changes often delays the identication
of the appropriate dose by overcorrection.
The narrow therapeutic window of thyroid hormone
efcacy is another aspect that patients should understand.
In particular, the effect of changing thyroid hormone
preparations, from one brand to another, or to generic
preparations, may change the patients response to the
drug. Patients should be encouraged to be consistent
about the preparation that they use, or, if a change is
unavoidable, to recheck their thyroid-stimulating hormone
levels a month after a change to document the effect. This
has been well documented in the medical and lay litera-
ture, and most pharmacists are also sensitive to this
issue.2130
A more frequent problem is the addition or subtraction
of some other chronic medication, such as oral contracep-
tive pills or estrogen replacement therapy, that changes
the serum protein binding of the thyroid hormone dose.
Patients should be informed of this potential effect and
the need to redocument and adjust thyroid hormone
dosing after these changes in other medications.
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1. Kitamura Y, Shimizu K, Nagahama M, et al. Immediate
causes of death in thyroid carcinoma: clinicopathological
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84:40434049.
2. Rudow M, Hill AB, Thompson NW, Finch JS. Helium-
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3. Allo MD, Thompson NW. Rationale for the operative
management of substernal goiters. Surgery 1983;94:969
977.
4. Sippel RS, Gauger PG, Angelos P, et al. Palliative
thyroidectomy for malignant lymphoma of the thyroid.
Ann Surg Oncol 2002;9:907911.

5. Farrar WB, Cooperman M, James AG. Surgical manage-
ment of papillary and follicular carcinoma of the thyroid.
Ann Surg 1980;192:701704.
6. Thompson NW, Nishiyama RH, Harness JK. Thyroid
carcinoma: current controversies. Curr Probl Surg 1978;
15:167.
7. Schroder DM, Chambous A, France CJ. Operative
strategy for thyroid cancer, is total thyroidectomy worth
the price? Cancer 1986;58:2320.
8. Clark OH, Levin K, Zeng QH, et al. Thyroid cancer: the
case for total thyroidectomy. Eur J Cancer Clin Oncol
1988;24:305313.
9. Ley PB, Roberts JW, Symmonds RE Jr, et al. Safety and
efcacy of total thyroidectomy for differentiated thyroid
carcinoma: a 20-year review. Am Surg 1993;59:110114.
10. Tartaglia F, Sgueglia M, Muhaya A, et al. Complications
in total thyroidectomy: our experience and a number of
considerations. Chir Ital 2003;55:499510.
11. Rosato L, Avenia N, Bernante P, et al. Complications of
thyroid surgery: analysis of a multicentric study on 14,934
patients operated on in Italy over 5 years. World J Surg
2004;28:271276.
12. Winer KK, Ko CW, Reynolds JC, et al. Long-term
treatment of hypoparathyroidism: a randomized controlled
study comparing parathyroid hormone-(1-34) versus
calcitriol and calcium. J Clin Endocrinol Metab 2003;88:
42144220.
13. Olson JA Jr, DeBenedetti MK, Baumann DS, Wells SA Jr.
Parathyroid autotransplantation during thyroidectomy.
Results of long-term follow-up [see comment]. Ann Surg
1996;223:472478; discussion 478480.
14. Thomusch O, Machens A, Sekulla C, et al. The impact of
surgical technique on postoperative hypoparathyroidism in
bilateral thyroid surgery: a multivariate analysis of 5846
consecutive patients. Surgery 2003;133:180185.
15. Rea JL, Khan A. Clinical evoked electromyography for
recurrent laryngeal nerve preservation: use of an endotra-
cheal tube electrode and a postcricoid surface electrode.
Laryngoscope 1998;108:14181420.
16. Otto RA, Cochran CS. Sensitivity and specicity of
intraoperative recurrent laryngeal nerve stimulation in
predicting postoperative nerve paralysis. Ann Otol Rhinol
Laryngol 2002;111:10051007.
17. Stojadinovic A, Shaha AR, Orlikoff RF, et al. Prospective
functional voice assessment in patients undergoing thyroid
surgery [see comment]. Ann Surg 2002;236:823832.
40 THYROID SURGERY 405
18. Burkey SH, van Heerden JA, Thompson GB, et al.
Reexploration for symptomatic hematomas after cervical
exploration. Surgery 2001;130:914920.
19. Abbas G, Dubner S, Heller KS. Re-operation for bleeding
after thyroidectomy and parathyroidectomy. Head Neck
2001;23:544546.
20. Mazzaferri EL. An overview of the management of
papillary and follicular thyroid carcinoma. Thyroid 1999;
9:421427.
21. Mikosch P, Obermayer-Pietsch B, Jost R, et al. Bone
metabolism in patients with differentiated thyroid carci-
noma receiving suppressive levothyroxine treatment.
Thyroid 2003;13:347356.
22. Sawka AM, Gerstein HC, Marriott MJ, et al. Does a
combination regimen of thyroxine (T4) and 3,5,3-
triiodothyronine improve depressive symptoms better than
T4 alone in patients with hypothyroidism? Results of a
double-blind, randomized, controlled trial. J Clin Endo-
crinol Metab 2003;88:45514555.
23. Walsh JP, Shiels L, Lim EM, et al. Combined thyroxine/
liothyronine treatment does not improve well-being,
quality of life, or cognitive function compared to thyrox-
ine alone: a randomized controlled trial in patients with
primary hypothyroidism [see comment]. J Clin Endocrinol
Metab 2003;88:45434550.
24. Walsh JP. Dissatisfaction with thyroxine therapycould
the patients be right? Curr Opin Pharmacol 2002;2:717
722.
25. Saravanan P, Chau WF, Roberts N, et al. Psychological
well-being in patients on adequate doses of L-thyroxine:
results of a large, controlled community-based question-
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577585.
26. Woeber KA. Levothyroxine therapy and serum free
thyroxine and free triiodothyronine concentrations. J
Endocrinol Invest 2002;25:106109.
27. Wiersinga WM. Thyroid hormone replacement therapy.
Horm Res 2001;56(suppl 1):7481.
28. Fischman J. Reports of thyroid drugs demise were
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29. What is going on with levothyroxine? Med Lett Drugs
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30. Bell DS, Ovalle F. Use of soy protein supplement and
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Pract 2001;7:193194.
41
Parathyroid Surgery
Lawrence T. Kim, MD
INTRODUCTION
Surgical treatment of parathyroid disease is highly success-
ful, with a very low complication rate. In expert hands,
the cure rate of hyperparathyroidism approaches 99% in
large series, whereas signicant morbidity may be very
rare.1 As with all operations, however, the results achieved
by experts depends on long-term experience with the
potential difculties of the procedure. The purpose of
this chapter is to expand on these potential problems so
that the reader may either avoid them or deal with them
appropriately.
DIAGNOSIS
Hyperparathyroidism is usually a straightforward diag-
nosis. However, misdiagnosis is a common cause of
operative failure. The combination of hypercalcemia,
elevated parathyroid hormone (PTH), and elevated
urinary calcium is diagnostic. However, many patients
do not t this simple paradigm. The surgeon is often
faced with patients who have marginal laboratory abnor-
malities or diseases that may masquerade as hyperpara-
thyroidism. Surgery performed in cases in which
parathyroid adenoma or hyperplasia is absent is frustrat-
ing for the surgeon and dangerous for the patient. This
section briey focuses on disorders that commonly
present a diagnostic challenge. The collaboration of an
endocrinologist who is expert in parathyroid disease and
mineral metabolism cannot be overemphasized. Not
infrequently, patients referred to the author for hyper-
parathyroidism do not in fact have the disease. The
surgeon always has the nal responsibility for establish-
ing the correct diagnosis.
Normocalcemic hyperparathyroidism, as its name
suggests, is characterized by normal serum calcium, at
least on most occasions. Normocalcemic hyperparathy-
roidism has been clearly dened as an entity and may
represent a very early stage of the disease.2 In these cases,
PTH may be only slightly elevated and is usually lower
than in patients with hypercalcemia. Urinary calcium
excretion may occasionally be markedly elevated which
helps to conrm the diagnosis of hyperparathyroidism.
Coexisting vitamin D deciency, a common occurrence,
may mask the hypercalcemia that would normally
occur.
Hyperparathyroidism may occur as part of a genetic
syndrome. These syndromes include familial isolated
hyperparathyroidism, multiple endocrine neoplasia (MEN)
1, MEN 2a, and hyperparathyroidismjaw tumor syn-
drome. It is vital to obtain family history for all patients
with hyperparathyroidism. Questions should be relevant
not only to hyperparathyroidism but also to other mani-
festations of these syndromes. Specic questions about
peptic ulcer disease, Zollinger-Ellison syndrome, thyroid
tumors, adrenal tumors, and pituitary tumors should be
included. Failure to diagnose a genetic syndrome may lead
to inappropriate surgery for the patient.
Familial hypocalciuric hypercalcemia (FHH) is an
uncommon disease characterized by mild elevations of
serum calcium, normal to modestly elevated PTH, and a
low urinary calcium. It is an autosomal dominant genetic
disease. Approximately two thirds of patients have a muta-
tion in the calcium-sensing receptor. A 24-hour urinary
calcium usually shows very low calcium excretion. The
best test to differentiate FHH from hyperparathyroidism
is the ratio of urinary calcium to creatinine clearance (UCa
SCr/UCr SCa, where U is the 24-hr urinary excretion
and S is the serum concentration).3 Most patients with
FHH will have a ratio less than 0.01. It is important to
rule out FHH prior to surgical exploration, particularly if
the serum calcium and PTH are nearly normal. This
disease will usually not require surgical treatment.
CHOICE OF OPERATION
The gold standard surgical approach for primary hyper-
parathyroidism is full neck exploration with visualization
of all parathyroid glands. This has the advantage of an
extremely high cure rate in expert hands. But dissection
is fairly extensive, even in simple cases, which results in a
longer operative time, longer hospital stay, and more
patient discomfort. A newer technique for parathyroidec-
tomy is the directed parathyroidectomy. With the directed
parathyroidectomy, preoperative imaging is used to locate
an abnormal gland, and only that gland is visualized and
 408 SECTION V: ENDOCRINE SURGERY

removed. A variation of this technique is to use intra-

operative radioactivity detection to locate the abnormal Full Neck Exploration,
gland to facilitate localization and dissection. The intra-
operative parathyroid hormone (IOPTH) assay is used to Including Subtotal
conrm that no other abnormal tissue remains. Advan-
tages of the minimally invasive technique include a shorter and Total
operative time, a much smaller incision with less dissec-
tion, a shorter hospital stay (usually done as an outpa- Parathyroidectomy
tient), and a quicker recovery. Directed parathyroidectomy
particularly lends itself to performance under local anes- INDICATIONS
thesia.4,5 A disadvantage is that the cure rate may be lower
with this procedure, especially if the IOPTH assay is Primary hyperparathyroidism (especially in cases
omitted. However, the risks of reoperation are believed to without availability of IOPTH monitoring or with no
be lower, given the fact that most of the neck will not visible lesion after preoperative imaging)
have been dissected. The approach should be chosen Familial hyperparathyroidism
based on the available technology and the clinical details Secondary hyperparathyroidism
of the patient (Fig. 411). Calciphylaxis

Diagnosis of hyperparathyroidism

Intraop PTH assay

available?

Yes
No
Good ultrasound and
sestamibi available?

Yes
No

Full neck Plan directed

exploration parathyroidectomy

No

Gland seen on
imaging?

Yes

Gland seen on
Gland seen on Gland seen on
ultrasound and
ultrasound only. sestamibi only.
sestamibi.

Directed parathyroidectomy
Directed
with intraoperative gamma
parathyroidectomy Figure 411 Management
probe
algorithm for primary
hyperparathyroidism.
 41 PARATHYROID SURGERY 409

I
Figure 412 View of the left parathy-
roids. The view is of the left side of the neck.
The head is to the right. The thyroid is
retracted superiorly and to the patients
right (away from the viewer). The superior N
(S) and inferior (I) parathyroids are seen, as
is the recurrent laryngeal nerve (N). Of S
note is the typical relationship of the supe-
rior and inferior parathyroid glands to the
recurrent nerve, with the superior gland
posterior and the inferior gland anterior.

OPERATIVE STEPS ogy (Fig. 412). The parathyroid glands arise from the
third and fourth pharyngeal pouches. The superior
Step 1Transverse collar incision glands arise from the fourth pouch along with the C-
Step 2Vertical incision through strap muscles cells of the thyroid. They migrate inferiorly and typi-
Step 3Exposure of thyroid cally come to rest on the posterior aspect of the thyroid
Step 4Dissection and identication of parathyroids in the midbody of the gland, near the intersection of
Step 5Biopsy of parathyroids (optional) the inferior thyroid artery and the recurrent laryngeal
Step 6Removal of abnormal parathyroid(s) nerve. Because of its embryologic relationship with the
Step 7Thymectomy (included with total C cells, superior glands may occur within the substance
parathyroidectomy) of the thyroid. The inferior glands arise from the third
Step 8 Approximation of strap muscles pouch, which also gives rise to the thymus. These
Step 9 Closure of platysma glands migrate farther inferiorly than the superior
Step 10 Skin closure glands and are usually located near the tip of the infe-
rior pole of the thyroid. Because of their embryologic
Transverse Collar Incision
origin, they are frequently within the thymus or the fat
The incision is ideally placed within a transverse skin pad containing the thymic remnant. This fat pad lies
crease. A more inferior incision usually provides a more inferior to the thyroid and is bounded roughly by the
pleasing cosmetic result, although access to the superior thyroid superiorly, the sternocleidomastoid muscles
pole of the thyroid gland may be difcult. and recurrent laryngeal nerves laterally, the trachea pos-
teriorly, the aortic arch inferiorly, and the strap muscles
Dissection and Identication of Normal and and sternum anteriorly. Inferior parathyroid glands are
Abnormal Parathyroids somewhat more prone than superior glands to be found
in unusual locations.
Failure to Locate an Abnormal Parathyroid
All parathyroid glands can migrate into unusual or
Consequence ectopic locations. Superior glands may be found near
Noncurative operation. the superior pole of the thyroid along the course of the
Grade 24 complication superior thyroid artery. Parathyroids may occur anywhere
along the posterior or lateral surface of the thyroid gland.
Repair They are frequently just under the thyroid capsule and
Reoperation. may be thinned considerably from pressure applied by the
surgeon during dissection or retraction. Frequent inspec-
Prevention tion of the thyroid during the dissection (and during
Intraoperative localization of the parathyroids requires thyroidectomy) may reveal these subcapsular glands.
an intimate familiarity with their anatomy and embryol- Either superior or inferior parathyroids may be within the
 410 SECTION V: ENDOCRINE SURGERY
substance of the thyroid parenchyma and undetectable
grossly. Ultrasound either preoperatively or intraopera-
tively may help locate these glands. Parathyroids may lie
posteriorly near the esophagus and even in the retropha-
ryngeal or retroesophageal space. Glands may also be
found in the carotid sheath. As mentioned previously,
inferior glands may be found within the thymus or its
associated fat pad. Thymic tissue can easily be mistaken
for a parathyroid adenoma. Thymic tissue is more gray in
color, slightly more dense, and less vascular than the
typical adenoma. Inferior parathyroids may migrate as
inferiorly as the heart. Therefore, they can be out of reach
from a cervical incision, although this is distinctly unusual.
The surgeon should make every attempt to carry the
search down to and along the innominate artery and aortic
arch as long as the patients body habitus allows a safe
dissection.
In addition to unusual locations, there may be more
than four parathyroid glands. In his classic anatomic
study, Gilmour6 found that 6.5% of cadavers had more
than four parathyroids. Other studies have found a lower
incidence.7 Although some studies including these have
shown fewer than four glands in some subjects, one
can never be certain if other glands have simply been
overlooked.
During dissection of parathyroids, meticulous tech-
nique is required. Lighting and magnication are critical
to successful parathyroid surgery. A headlight is useful,
particularly when working through small incisions, and
loupes provide a signicant advantage. A bloodless eld
must be maintained at all times. Staining with blood
impairs detection of subtle colorations. thereby making
identication of parathyroids more difcult. A useful tech-
nique to expose the gland is to grasp the overlying tissue
with ne forceps, nicking the tissue with ne scissors or
occasionally cautery, and gently pulling the tissue apart
between forceps. Gentle spreading with a ne instrument
is also useful. Care must be taken, however, not to disrupt
ne blood vessels, which may cause pesky bleeding. Indis-
criminate use of electrocautery may damage a parathyroid
or recurrent laryngeal nerve.
If a full exploration is completed and only three normal
glands are found, what should be done? In almost all
cases, there is an adenoma somewhere. Assuming that all
of the areas for ectopic location have been explored, a
thymectomy should be performed rst. That tissue should
be carefully inspected for the presence of a parathyroid. A
thyroid lobectomy would then be indicated if no adenoma
is found. If the surgeon or pathologist still cannot nd
the gland after sectioning the thyroid lobe or thymus, the
search must be continued until the entire neck from the
larynx to the aortic arch and posteriorly to the vertebrae
have been explored. Avoidance of this difcult situation is
one of the strongest arguments for preoperative parathy-
roid imaging. In these difcult cases, the IOPTH assay is
also very useful if available.
Failure to Recognize Multigland Disease
Consequence
Noncurative operation or early recurrence.
Grade 24 complication
Prevention
The gold standard for differentiation between normal
and abnormal glands is their gross appearance to an
experienced surgeon. As mentioned previously, current
parathyroid imaging studies are poor at detecting mul-
tigland parathyroid disease such as multiple adenomas
or hyperplasia. Therefore, imaging of a gland does not
mean that it is the only abnormal gland. Normal para-
thyroid glands usually weigh 30 to 70 mg and have a
yellowish-brown color variously described as salmon
or peanut butter. Visually, the typical size is about
that of a lentil, but they may range in size from that of
a plump grain of rice to a attened, elongated pea.
Parathyroids are, like all other endocrine glands, highly
vascular and bleed briskly if biopsied.
Adenomas are often more of a deep red color than
normal parathyroids (Fig. 413). A typical appearance is
that of a chicken heart. In some cases, especially smaller
adenomas, a rim of normal parathyroid tissue can be seen
adjacent to the adenoma. In very small adenomas, color
alone may distinguish them from normal parathyroids.
Adenomas can vary in size from 1 to 2 mm and encom-
passed completely within a normal parathyroid to walnut-
sized or even larger. A typical adenoma is the size and
shape of a kidney bean. Adenomas are universally soft. A
hard adenoma must lead one to consider parathyroid
cancer. Lymph nodes and thyroid tissue also are typically
rmer than a parathyroid adenoma.
Hyperplastic glands are also highly variable in size.
Some hyperplastic glands are only slightly larger than
normal and have a normal color and appearance. Other
hyperplastic glands may grow to considerable size. Small
hyperplastic glands may look exactly the same as an
adenoma. Large ones tend to be rmer than adenomas
and often lack the ruddy appearance of an adenoma.
Hyperplastic glands usually do not grow uniformly, and
there can be an order of magnitude variation in size within
one patient.
Adenomas may be multiple.8 Therefore, removal of
even a large, typical adenoma may not result in a cure.
Currently, the best modalities to ensure a curative opera-
tion are a full neck exploration to grossly evaluate all
parathyroids or use of the IOPTH assay.
Failure to Locate Four (All) Parathyroids after
Discovery of an Adenoma
Consequence
Probably none; possibly failure to diagnose multigland
disease.
Grade 13 complication
 41 PARATHYROID SURGERY 411

S
I

Figure 413 Left superior parathyroid

adenoma. The view is from roughly the
same perspective as in Figure 412. The
superior gland (S) is enlarged and ruddy with
the typical appearance of an adenoma. Note
its lack of surface vasculature, which helps A
distinguish it from thyroid tissue (T). Also N
seen are the inferior parathyroid (I), the
recurrent laryngeal nerve (N), and the infe-
rior thyroid artery (I).

Prevention for the patient. As always, intraoperative consultation

If the initial dissection shows a parathyroid adenoma,
the surgeon is often faced with the dilemma of deter-
mining when enough dissection is enough. Clearly,
the standard is to complete the dissection until four
glands are identied. Unless the IOPTH assay is used
(see later), less than a full dissection will probably result
in more treatment failures. Parathyroid disease may be
manifested by two or even three distinct adenomas.
Therefore, nding one abnormal gland and one normal
gland on one side is not denitive. Knowing, however,
that 85% or so of hyperparathyroidism is caused by a
single adenoma, the odds are with the surgeon if she
or he stops dissection. However, expert parathyroid
surgeons should expect a 98% to 99% cure rate. There-
fore, most experts would recommend that dissection
be continued until four glands are found. However,
there are patients in whom an adenoma has been found,
two other normal glands have been found, both sides
of the neck have been explored, and a fourth gland
cannot be found. In the case of adenoma, normal
glands may be suppressed and may even be smaller
than normal. This may make nding that last normal
gland very difcult. If a diligent exploration has been
carried out and the surgeon feels that the existence of
another sizeable adenoma within the dissected area is
unlikely, it is reasonable to stop. Certainly, if the
surgeon feels that further dissection would increase the
possibility of surgical morbidity, the risks of further
dissection outweigh any potential benet. When making
the decision to stop any further search, however, the
surgeon should always consider that a repeat dissection
in the future will be far more difcult and hazardous
from another experienced surgeon is appropriate in
difcult cases.
Injury to the Remaining Glands
Consequence
Hypoparathyroidism.
Grade 4 complication
Repair
Reimplantation of normal parathyroid if suspected.
Prevention
Extreme care must be taken to avoid damage to the
blood supply of normal glands. Devascularized glands
rapidly become dusky and eventually turn very dark. If
this occurs to a normal gland, it should immediately be
excised and placed on ice until it can be reimplanted
(see under Parathyroid Autotransplantation, later).
Injury to the Recurrent Laryngeal Nerve
Consequence
Vocal cord paralysis; hoarseness.
Grade 4 complication
Repair
Primary repair of nerve (immediately). Vocal cord
medialization (later).
Prevention
All parathyroid surgeons should be very familiar with
the course and potential aberrant locations of the recur-
rent laryngeal nerve so as not to injure it. Even if the
 412 SECTION V: ENDOCRINE SURGERY
nerve is not cut, it may be injured by dissection in close
vicinity. Cautery should be used only when one is
certain that electric current will not injure a nearby
nerve. Bipolar cautery is safer when working near the
nerve. Clips and sutures may impinge on the nerve or
may kink it, thereby impairing its blood supply.
Biopsy of the Parathyroids
Frozen section may be used to identify parathyroid glands.
This is most useful for simple conrmation that the tissue
in question actually is parathyroid. Differentiation between
adenoma and hyperplasia on histology is unreliable. Frozen
section can be useful if appearances are unusual or confus-
ing. It is usually optional and becomes less necessary as
surgeon experience increases. It is mandatory, however,
in cases in which a gland will be cryopreserved or reim-
planted (see later), because misidentication may lead to
disaster. Frozen section is not generally useful in distin-
guishing an adenoma from hyperplasia. For that, the
surgeon will need to rely on inspection of all glands or
the IOPTH assay.
If a parathyroid needs to be biopsied for identication,
care must be taken to avoid damage to the blood supply
to the gland. A tip of the gland is exposed away from the
vascular pedicle. Fine scissors are placed across this tip
with the gland well proximal to the tip of the scissors. If
only the scissor tip is used, the gland has a tendency to
slide out before it is transected completely. As with all
endocrine organs, the transected parathyroid should bleed
briskly (for its size). Bipolar electrocautery is used spar-
ingly for hemostasis. Monopolar cautery should not be
used or should be used only at very low settings to avoid
injury to the remaining gland and blood supply.
Removal of Abnormal Parathyroids
Disruption of the Capsule
Consequence
Possible parathyromatosis.
Grade 3 complication
Repair
Reoperation at a future date.
Prevention
When dissecting a parathyroid, care should be taken to
avoid damage to the capsule. Spilling cells from an
adenoma may lead to parathyromatosis (i.e., multiple
foci of enlarging parathyroid tissue). This may cause
recurrent disease at a later date and can be a difcult
problem to correct. While dissecting a normal-sized
parathyroid, the surgeon should avoid grasping or
retracting the gland directly. Pressure or retraction on
adjacent tissue should expose the gland. However,
adenomas sometimes require direct traction, especially
when working through a small incision. If the adenoma
must be grasped, the whole gland may be gently grasped
with a larger forceps such as a DeBakey. Small, ne
forceps are too prone to puncture the capsule. Gentle
pressure only can be used, because too rm a grip will
crush the gland. When rmer traction is required, the
gland may be pushed or pulled with open DeBakey
forceps. The capsule alone should not be grasped
because it is likely to tear. Once the vascular pedicle is
ligated, the suture may be cut relatively long to provide
a handle to pull the gland from surrounding tissue.
After ligation of this pedicle, the whole gland can
usually be pulled free of surrounding areolar tissue with
gentle traction and blunt dissection.
Subtotal Parathyroidectomy
Subtotal parathyroidectomy is chosen in cases of sporadic
four-gland hyperplasia. It may also be chosen by some
surgeons for secondary hyperparathyroidism. Hyperplasia
is diagnosed by nding diffuse enlargement of all glands.
With hyperplasia, the size of the abnormal parathyroids is
highly variable, both within a single patient and between
different patients. In some patients, the glands may be
virtually normal in size. In these cases, a careful search for
an ectopic supernumerary gland and a thymectomy should
be undertaken, although these normal or near-normal
size glands may in fact be the cause of the disease. If a
subtotal parathyroidectomy is chosen, the most normal-
appearing gland is chosen to remain in situ. If there is
more than one good candidate, the gland that would be
most accessible at reoperation is chosen to remain in situ.
If the gland chosen to remain is signicantly enlarged, the
remnant is trimmed to allow approximately 50 to 70 mg
of normal parathyroid tissue to remain. Technically, this
is performed as described earlier under Biopsy of the
Parathyroids. The remnant is marked with a nonabsorb-
able suture (polypropylene) and clips for identication at
a later date should reoperation be required. The suture is
usually easier to nd during operation, and clips will facil-
itate sonographic or radiographic localization. Care must
be used to ensure that the blood supply to the gland is
not damaged during dissection. If there is a question
about the viability of the remnant, complete excision
should be performed followed by autotransplantation of
tissue whose viability is certain.
Supernumerary Glands
Consequence
Persistent hyperparathyroidism.
Grade 24 complication
Repair
Reoperation.
Prevention
The possibility of supernumerary glands is a much more
signicant problem when operating for hyperplasia.

Anatomic studies have shown a prevalence of super-
numerary parathyroid glands from 2.5% to 11%.6,7,9
Retained, unidentied glands left in situ may be the
source of recurrent or persistent disease. A careful
search should be made at the time of operation for
supernumerary glands. Presumably, the IOPTH assay
could be used to prove that no source of PTH has been
left. It has been shown that the IOPTH assay should
be performed after resection of multigland disease.10,11
Proof that this assay can rule out supernumerary glands
is lacking, but practically, if the IOPTH level falls to
very low levels, the likelihood of a signicant gland
remaining is low.
Total Parathyroidectomy
Total parathyroidectomy with autotransplantation can be
performed for genetic disease including familial hyperpara-
thyroidism and MEN. It may also be chosen for secondary
hyperparathyroidism due to renal failure. Total parathy-
roidectomy without autotransplantation is indicated for
calciphylaxis. Some authors have also recommended total
parathyroidectomy without autotransplantation in renal
failure, although this is currently a minority opinion.12 An
advantage of total parathyroidectomy with autotransplan-
tation is a potential decrease in recurrence of hyperpara-
thyroidism. In one small, randomized, prospective trial,
patients with secondary hyperparathyroidism treated this
way had a lower recurrence over those treated with sub-
total parathyroidectomy.13 However, long-term follow-up
suggests that many patients with secondary hyperparathy-
roidism due to renal failure may recur regardless of
technique, although the data again favor total parathy-
roidecomy.14 In any case, reoperation on autotransplanted
glands in the forearm is less risky to the patient than
reoperating in the neck. Locating hyperfunctioning glands
within a muscle belly is often difcult. Ultrasound preop-
eratively may occasionally show the location of an enlarged
autotransplant.
If a total parathyroidectomy is chosen (with or without
autotransplantation), a cervical thymectomy should be
included as part of the procedure for removal of poten-
tial supernumerary glands. A thymectomy is performed
by removing all tissue between the thyroid superiorly,
the aortic arch inferiorly, the trachea posteriorly, the
recurrent laryngeal nerves laterally and posteriorly, and
the strap muscles anteriorly. Dissection is begun at the
inferior border of the thyroid. The recurrent nerves are
traced inferiorly bilaterally, and these serve to mark the
posterior and lateral extent of the dissection. All tissue
is elevated off the trachea. Thymic and fatty tissue is
elevated out of the mediastinum by gentle traction with
Allis clamps. Dissection is completed by transecting
the tissue at or just above the aortic arch. A harmonic
scalpel is useful to cut through this amorphous
tissue.
41 PARATHYROID SURGERY 413
Temporary Postoperative Hypocalcemia
Consequence
Symptoms of hypocalcemia (e.g., muscle spasm,
paresthesias).
Grade 1 complication
Repair
Calcium should be checked every 6 to 8 hours after
total parathyroidectomy. Patients will usually require
intravenous calcium infusion beginning 24 to 72 hours
after surgery. They may then be started on oral supple-
mentation and calcitriol until stable levels can be main-
tained. Over several weeks, the supplementation can be
gradually decreased as the residual or autotransplanted
parathyroid becomes functional.
Prevention
Hypocalcemia is the routine after total parathyroidec-
tomy with autotransplantation. Its absence should
cause worry that a supernumerary gland has been
overlooked.
Wound Closure
Inaccurate Closure of the Platysma
Consequence
Poor cosmetic result.
Grade 1 complication
Repair
Possibly, wound revision in extreme cases.
Prevention
Closure of the platysma is important for a good cos-
metic result. In placing sutures into the platysma, it is
easy to hook the dermis with the needle. This results
in a dimpling of the skin that may remain long term.
Accurate closure of this muscle also helps to prevent
step-offs that produce an unsightly result.
Directed
Parathyroidectomy
INDICATIONS
Sporadic primary hyperparathyroidism WITH
Available IOPTH monitoring
Positive preoperative imaging
Sporadic primary hyperparathyroidism with positive
preoperative imaging but WITHOUT available IOPTH
monitoring (controversial).
 414 SECTION V: ENDOCRINE SURGERY

OPERATIVE STEPS

Step 1 Preoperative imaging

Step 2 Preoperative injection with 99Tc sestamibi
(optional)
Step 3 Insertion of peripheral intravenous shunt for
blood draws
Step 4 Blood sample for baseline IOPTH assay
Step 5 Small transverse neck incision
Step 6 Identication of parathyroid adenoma
Step 7 Blood sample for preexcision IOPTH assay
Step 8 Excision of parathyroid
Step 9 Blood samples 5 and 10 minutes postexcision A
for IOPTH assay
Step 10 Extension of operation to full exploration if indi-
cated by assay
Step 11 Closure

Preoperative Imaging
Prior to widespread acceptance of the directed parathy-
roidectomy, parathyroid imaging was widely considered
unnecessary because a full neck exploration would be
performed anyway. The radiologist John Doppman was
widely quoted that, The only localization technique
needed is to localize an experienced parathyroid surgeon.
Increased attention to and acceptance of directed parathy-
roidectomy have led to wider use of preoperative parathy-
roid imaging. Parathyroid imaging can be extremely
helpful, but it has major pitfalls. The two most commonly
used techniques are ultrasound examination and nuclear
scintigraphy with 99Tc-labeled sestamibi.
Ultrasound is convenient, inexpensive, and potentially
very accurate. It may be performed in the surgeons ofce
at the time of the initial visit.15,16 The exact sensitivity and
specicity of ultrasound have varied widely in the litera-
ture, no doubt because of these technical issues. Sensitiv-
ity in good hands is probably around 70% to 80%, with
specicity over 90%. Because the results of ultrasound vary
so widely, it is important that a parathyroid surgeon
understand the accuracy in his or her institution. If detec-
tion rates are consistently under 50%, the technique is
clearly not being used to its potential. Accuracy may be
improved by working with radiology to encourage a radi-
ologist and a sonographer to become expert in this area.
Another alternative is for the surgeon to perform the
ultrasound (Fig. 414). It is well documented that ultra-
sound can be expertly performed by surgeons in these
focused areas.15,17,18 Training in ultrasound is available
from the American College of Surgeons and a variety of
other sources. There are major advantages to the surgeon
performing his or her own ultrasound in appreciating the
anatomic location of the lesion. Ultrasound can reveal
fairly small adenomas (34 mm on occasion), but it is not
particularly good at detecting ectopic parathyroids, espe-
cially low in the mediastinum. Ultrasound is also poor at
detecting multigland disease, especially hyperplasia. Even
B
Figure 414 A, Transverse ultrasound view of a left superior
parathyroid adenoma. Note the homogeneous, hypoechoic lesion.
B, Longitudinal ultrasound view of the same left superior parathy-
roid adenoma.
large hyperplastic glands can be missed, probably because
their echotexture and density may be the same as the
thyroid or surrounding tissue.
The sestamibi scan is also widely available. Sestamibi
(Cardiolite) was initially developed for cardiac imaging. It
was subsequently found to concentrate in parathyroid
adenomas and has since been widely used for parathyroid
imaging. Sestamibi accumulates in mitochondria, which
are abundant in parathyroid cells. This scan is somewhat
time-consuming for the patient but is very low risk. The
patient receives an injection of the labeled compound.
After a short period of time (15 min), scintigraphy is
performed of the neck and upper chest. This will show
uptake in the thyroid, parathyroid, and salivary glands.
Occasionally, a parathyroid will be visible because it is
either ectopic or sufciently large to cause asymmetry of
the thyroid image, but usually the parathyroid adenoma
is not visible in this early image. Over a period of time,
the sestamibi will wash out of the thyroid but remain in
the parathyroid. An image is taken 2 to 3 hours after the
initial injection to look for retention in a parathyroid

10 MINUTE POST INJECTION
3 HOUR POST INJECTION
Figure 415 Typical sestamibi scan indicates the presence of a right inferior parathyroid adenoma. Note the early uptake in the thyroid
gland that dissipates in the 3-hour view. The parathyroid is indicated by the arrows. The salivary glands are shown by the intense uptake
in the upper part of the images.
(Fig. 415). This imaging technique is particularly useful
in locating ectopic parathyroid glands, including the
mediastinum. The main problems with sestamibi scanning
are sensitivity and its poor efcacy in detecting multigland
disease. Although, as with ultrasound, a wide range of
accuracy with sestamibi scanning has been reported, on
average, a sestamibi scan should show a lesion in about
60% to 80% of cases.1921 If a gland is seen, the likelihood
that it is indeed a parathyroid is very high. Multiplane
scans should be obtained for the best possible localization.
Sensitivity and specicity can also be improved with
single photon emission computed tomography (SPECT)
imaging. A potential cause of a false-positive scan can be
uptake in a thyroid nodule. Abnormal thyroid tissue may
trap sestamibi, yielding a false-positive result. Correlation
with ultrasound in these cases can be very helpful. The
combination of high-quality ultrasound and sestamibi is
complementary, and many parathyroid experts use both
techniques preoperatively.
41 PARATHYROID SURGERY 415
3 HOUR POST INJECTION
Other imaging tests are occasionally useful preopera-
tively. Computed tomography (CT) scanning is not an
imaging method of choice because of poor sensitivity,
but it can show adenomas on occasion. Magnetic reso-
nance imaging (MRI) can be helpful, particularly for
locating an ectopic gland in the mediastinum. Positron-
emission tomography (PET) has been performed using
11
C-methionine with results similar to those of sesta-
mibi.22,23 Another alternative, used primarily after a failed
exploration, is venous sampling from neck veins by an
experienced interventional radiologist to detect an area of
high PTH secretion. Usually, this technique should be
reserved for referral centers. Further developments in
imaging are necessary for improved resolution, sensitivity,
and specicity.
If a preoperative imaging study shows a parathyroid
lesion, the surgeon is faced with the choice of a directed
parathyroidectomy or the standard complete neck explo-
ration. With the development of the IOPTH assay in the
 416 SECTION V: ENDOCRINE SURGERY
1990s (see later), more and more surgeons are choosing
a directed parathyroidectomy. If the ultrasound shows a
typical parathyroid adenoma, there should be enough ana-
tomic information to readily guide the surgeon to the
abnormal gland. If the gland shows only on sestamibi
scan, anatomic information is limited. In this case, intra-
operative detection using a hand-held gamma detector
(see later) may speed dissection.
Intraoperative localization with ultrasound may be done
but is not as good as preoperative ultrasound. In this
technique, the incision is lled with saline, and imaging is
performed through the saline. Sterile ultrasound gel may
also be used on the skin or on solid organs. Intraoperative
ultrasound may be performed to inspect the thyroid when
an intrathyroidal parathyroid is suspected. Its use to local-
ize an adenoma in other locations during surgery is more
problematic. The numerous electrical devices present in
an operating room often degrade the image on the ultra-
sound screen. Air introduced into the tissues during
dissection is particularly troublesome because tiny air
bubbles scatter the ultrasound beam and degrade the
image considerably. This author typically uses ultrasound
preoperatively in the clinic or just before incision to plan
the incision, particularly in reoperative cases.
Intraoperative Radio-guided Localization
If this procedure is chosen, the patient is taken to nuclear
medicine for injection with 99Tc Sestamibi the morning of
surgery. A hand-held gamma probe with collimator is then
used to localize the area of highest emission, similar to the
technique used with sentinel lymph node biopsy. These
hand-held probes are now found in most operating rooms,
often for use with sentinel lymph node biopsy. Dissection
is carried toward the area of highest activity in a fashion
similar to that used for a sentinel node biopsy.
Some authors have advocated routine use of intraop-
erative gamma detection.24 Advantages include better
incision planning and a focused, directed dissection. In
this authors opinion, good sestamibi scanning along with
preoperative ultrasound provides adequate anatomic infor-
mation in most cases without the need for the intraop-
erative gamma probe. However, for cases in which a lesion
is seen on sestamibi scan but not ultrasound, especially in
reoperative cases or when an ectopic gland is suspected,
intraoperative gamma probe localization is very useful.
Intraoperative gamma detection is not useful if the sesta-
mibi scan performed in nuclear medicine does not detect
a parathyroid.
Intraoperative PTH Monitoring
The IOPTH assay has been used since the mid-1990s
to monitor PTH during surgery. PTH has a short half-
life, approximately 4 minutes. If an adenoma is removed,
the PTH level should fall rapidly. If other abnormal
glands remain, the level should fall to less of a degree.
Therefore, if the level falls appropriately, the gland in
question was a single adenoma. If it does not fall appro-
priately, other abnormal glands probably remain. This
allows the operation to be terminated without direct
visualization of the other glands. This concept was con-
rmed by Irvin and coworkers2527 and has been validated
by several other groups. IOPTH is measured at baseline
prior to or just after incision. Ideally, this should be
done from a peripheral venous line. The best placement
is usually in the saphenous vein at the ankle. However,
in practical terms, samples obtained from neck veins
(away from the parathyroid, such as an anterior jugular
vein) or arterial lines tend to have quite similar values.
It is important that a new sample be drawn as baseline
at the time of surgery rather than relying on previous
clinic levels. As the putative adenoma is dissected, just
prior to its removal, a second level is drawn, which is
termed the preexcision level. This level is important
because, on occasion, the PTH level may rise substan-
tially from manipulation during dissection. After the
gland is excised, levels are drawn at 5 minutes and 10
minutes after excision. Criteria for successful removal of
abnormal tissue is a drop of 50% at 10 minutes com-
pared with either the baseline or the preexcision level,
whichever is higher.
The IOPTH assay may be performed in the operating
room using a portable instrument. However, a dedicated
technician must be present to prepare and operate the
machine. This is often not cost effective for clinical labo-
ratory personnel. Direct transport to the laboratory by a
tube system or a courier is usually adequate. However,
direct communication between laboratory staff and oper-
ating room staff is crucial both prior to and during the
procedure. The instrument may require several hours of
setup and calibration time, making a last-minute request
for the testing impossible to fulll. The IOPTH assay,
although fast, is usually not back by the time the wound
is closed. It is important to remain in the operating room
with the sterile eld maintained until a denitive labora-
tory value returns. This author has, on several occasions,
had to reopen the neck based on the IOPTH results, even
though a typical adenoma was found.
Other disadvantages of the IOPTH assay are its cost
and lack of widespread availability. A separate setup to
perform IOPTH assays alone is often impractical for
hospitals with a small volume of parathyroidectomies.
However, newer instruments can be incorporated into the
general clinical laboratory to run these and other assays.
Such multifunction can greatly reduce the xed costs asso-
ciated with the assay, making its purchase more attractive
to hospitals. It is essential that the surgeon work closely
with a clinical laboratory specialist when determining how
best to make this test available.
False-Positive Drop in PTH Levels
Complication
Persistence of hyperparathyroidism.
Grade 2 complication

Repair
Reoperation.
Prevention
If the Irvin criteria are met, the false-positive rate
(falsely indicating complete resection) has been reported
from 6% (based on evaluation of all other glands)28
down to 0% (based on clinical cure rate).29 These data
raise the question as to whether some glands may be
enlarged but not hyperfunctional. Current data suggest
that this is indeed the case.18 Therefore, when inter-
preting studies that clearly show grossly abnormal
glands missed by the IOPTH assay, one must not
assume for certain that these glands would produce
clinical disease. More precise answers about the rela-
tionship between gross morphology and abnormal
function will await further developments in imaging. If
a failure does occur after directed parathyroidectomy
and reexploration is required, it may not be
as hazardous because most of the neck has not been
dissected.
Whereas the Irvin guidelines have proved very reliable,
certain patterns in the parathyroid level should raise
concern for the surgeon. If the level drops by about 50%
after 5 minutes, but does not drop by another 50% at
10 minutes, the surgeon should be concerned. For
example, if the baseline level was 150, the preexcision
level was 140, the 5-minute level was 60, and the 10-
minute level was 50, the criteria for a complete excision
have been met. However, one would expect the 10-
minute level to be around 30, given the half-life of PTH,
especially because the normal glands should be sup-
pressed. In these cases, another level can be drawn that
will usually resolve the question. If a 15- or 20-minute
level is the same or rising, further exploration is probably
warranted.30 However, if it has fallen further, the opera-
tion can probably be terminated. If signicant concern
remains, conversion to a full exploration is warranted.
However, some judgment and interpretation are vital.
Factors such as patient age, health, operative risk, desire
to avoid repeat surgery, and desire to avoid the cosmetic
and recovery disadvantages associated with complete
exploration should be considered. Strict adherence to
the Irvin guidelines is a safe, effective approach. But
attention to the patterns of PTH decline will occasion-
ally avoid an operative failure even when the criteria
are met.
Incision
For a directed parathyroidectomy, the location and length
of the incision may vary. With good localization using
either ultrasound or the hand-held gamma probe, the
location of the putative adenoma may be very accurately
identied prior to incision. Some surgeons prefer to make
the incision directly over the lesion and dissect through
the strap muscles at that location. The main advantage of
this approach is a direct, minimal dissection. This can be
41 PARATHYROID SURGERY 417
a signicant advantage for glands that are particularly
superior or inferior. This approach can also be especially
helpful in reoperative cases because the surgeon may be
able to operate in previously unviolated planes, allowing
a safer dissection. A disadvantage of this approach is that
conversion to a full neck exploration may require a new
incision. For directed parathyroidectomy, this author
prefers a transverse incision approximately 1.5 to 3 cm
long (longer for larger necks, occasionally smaller for thin
necks) centered in the midline. This is made within a skin
crease nearest the parathyroid. Small subplatysmal aps are
created, and the strap muscles are opened vertically in the
midline. The skin is retracted with a Weitlaner retractor.
The strap muscles and thyroid gland may be retracted with
an Army-Navy or similar retractor. This approach allows
exposure of a parathyroid adenoma in any typical location
and can, therefore, be used in cases in which preoperative
localization is uncertain. The main disadvantage is the
long distance between the incision and the adenoma in
certain cases making visualization and dissection difcult.
Although technically possible in some cases, use of this
small incision to identify all normal glands or subtle hyper-
plasia is usually not advisable. If it is suspected that a full
neck exploration will be required, a larger, standard
incision is preferable. In addition, if a search of ectopic
locations is necessary, conversion to the larger incision is
needed.
Identication of Parathyroid Adenoma
As described previously, under Full Neck Exploration.
Blood Sample for Preexcision IOPTH Assay
Usually, this is obtained after manipulation of the adenoma
but prior to ligation of the vascular pedicle.
Extension of the Operation to Full Exploration
if Indicated by the Assay
If the assay shows that the rst excision is not complete,
it is usually best to extend the incision for a full neck
exploration. Whereas it should be possible to access the
most common locations of a parathyroid adenoma from
a well-placed central incision, a larger incision allows for
easier detection of small adenomas or mildly hyperplastic
parathyroids.
Parathyroid
Autotransplantation
Parathyroid autotransplantation may be performed as an
adjunct to total parathyroidectomy or when a parathyroid
gland is devascularized unintentionally during thyroid
surgery. If this procedure is anticipated during total para-
 418 SECTION V: ENDOCRINE SURGERY
thyroidectomy, several specimen cups should be available
as well as an ice bath (this may be prepared either on the
sterile eld or outside the sterile eld). As each gland is
removed, it is placed in a sterile container along with a
few drops of saline. The container is tightly sealed and
then immediately immersed in ice. This slows the metab-
olism of the ex vivo gland. After all glands are removed,
the most normal-appearing gland is selected for auto-
transplantation. A portion of the chosen gland is sent for
frozen section to conrm its identity. At this time, if the
autotransplant will be placed in the forearm, the neck is
closed and the nondominant arm is extended, prepared,
and draped. A small incision is made over the exor
muscles, and dissection is carried down through the
muscle fascia. If the gland will be placed in the sterno-
cleidomastoid or strap muscle, a suitable muscle belly is
exposed.
About a 50- to 70-mg (about the size of a normal
parathyroid) piece of parathyroid tissue is selected and
dissected free of any attached fat or connective tissue. The
portion chosen for reimplantation is then minced into
small pieces. The author usually divides it into 8 to 12
pieces. Muscle bers are spread, and a piece is placed into
the pocket. The pocket is then closed with a polypropyl-
ene suture. Each piece is then placed in turn until all tissue
has been reimplanted. The author usually places 2 pieces
in each muscle pocket. Other surgeons use separate
pockets for each piece or place all pieces into a large
pocket. A few surgeons place the parathyroids in other
locations such as in subcutaneous fat.31,32
If a normal parathyroid is to be reimplanted during
thyroid surgery, an alternative technique has been sug-
gested. In this technique, the parathyroid is placed in a
small volume (1.52 ml) of saline and minced into very
ne pieces. These are then drawn into a syringe and
injected into the muscle belly. This has the advantages of
being fast and easy. A small randomized study of this
technique showed no disadvantages when compared with
the reimplantation technique.33 It should be cautioned,
however, that this should be limited to reimplantation of
normal glands only until its safety has been demonstrated
with abnormal glands. The concern would be that diffu-
sion of cells throughout a muscle might cause a signicant
problem if genetically abnormal or hyperplastic cells
continued their unregulated growth. Intuitively at least,
removal of this diffuse process in the case of recurrent
disease might be more difcult than using individual
pieces of tissue.
Permanent Hypoparathyroidism
Consequence
Severe hypocalcemia.
Grade 4 complication
Repair
Treated with high-dose calcium and calcitriol.
Prevention
Cryopreservation of excised parathyroid tissue. Perma-
nent hypoparathyroidism and chronic hypocalcemia
can be a debilitating complication of a total parathy-
roidectomy. If a total parathyroidectomy is performed,
cryopreservation provides a safety net should the auto-
graft fail or prove hypofunctional. Cryopreserved tissue
will remain viable for a long time, probably years. This
can be reimplanted if the need arises, although the need
for reimplantation is an admittedly rare event. If cryo-
preservation is to be performed, all parathyroid tissue
should be placed on ice immediately after excision. Any
tissue chosen for reimplantation or cryopreservation
should be examined by frozen section to ensure correct
identication. Tissue chosen for cryopreservation must
then be placed into medium supplied by the cryo-
preservation unit and transported to the facility on ice.
Most standard pathology laboratories will not be able
to perform cryopreservation. Facilities must follow
stringent guidelines and comply with federal and state
regulations. Many tertiary facilities will have this service
on site, but other facilities will likely need to send tissue
off-site for cryopreservation. Obviously, procedures
must be established well prior to the need for this
service. In the authors experience, the surgeon will
have to take the lead in ensuring that cryopreservation
is available.
Parathyroidectomy for Genetic Disease
Hyperparathyroidism may be part of a genetic syndrome
such as familial isolated hyperparathyroidism, MEN 1,
MEN 2a, or the hyperparathyroidismjaw tumor syn-
drome. Failure of recognition that the syndrome is genetic
is the greatest pitfall for the surgeon in dealing with these
diseases. A detailed and focused family history including
parathyroid, thyroid, adrenal, pituitary, and pancreatic
endocrine tumors should be elicited in all patients with
hyperparathyroidism. A history of severe peptic ulcer
disease should also be investigated. A review of surgery
for these familial syndromes has recently been presented.34
For MEN 1, a subtotal parathyroidectomy or total para-
thyroidectomy with autotransplantation is the procedure
of choice because all glands are usually affected. This
author prefers a total parathyroidectomy with autotrans-
plantation because persistent or recurrent disease should
be more easily treated. Permanent hypoparathyroidism is
a concern with this approach, although it has not been a
problem in the authors experience.
MEN 2a with known hyperparathyroidism is treated
similarly to MEN 1. The hallmark disease for MEN 2a,
however, is medullary thyroid cancer, and the surgeon
may be faced with a decision about how to handle the
parathyroid glands when treating the medullary cancer in
a patient who has not manifested any signs of hyperpara-
thyroidism. Genetic testing for the RET gene should be

done and a detailed family history obtained. Certain muta-
tions in RET that cause MEN 2a, such as C634, have a
higher risk than others to cause hyperparathyroidism. If
the family history is strong and gene sequencing reveals a
mutation known to cause hyperparathyroidism, more
aggressive treatment of the parathyroids is indicated. This
may include removal of normal-appearing glands and
autotransplantation in some cases. If the family history is
not denitive, however, the surgeon may proceed with
thyroidectomy to treat the medullary cancer and inspect
the parathyroids. Abnormal parathyroids should certainly
be removed, and a rational argument could be made to
proceed with total parathyroidectomy and autotransplan-
tation. If all parathyroids appear normal at thyroidectomy,
most surgeons would leave them in situ, although some
may opt, at least in certain circumstances, to proceed with
parathyroidectomy on at least one side of the neck. If the
parathyroids are left in situ, they should be marked with
polypropylene suture and clips for future identication.
Familial isolated hyperparathyroidism may cause solitary
adenomas or multigland disease, and treatment should
probably be the same as for isolated hyperparathyroidism.
The hyperparathyroidjaw tumor syndrome is a rare cause
of hyperparathyroidism. This syndrome has a high risk of
parathyroid cancer, which the surgeon must take into
account when planning the operation.
Parathyroid Cancer
Parathyroid cancer is rare and probably accounts for less
than 0.5% of cases of hyperparathyroidism. Failure to rec-
ognize parathyroid cancer in a patient with hyperparathy-
roidism is a signicant pitfall for the surgeon. Patients
who present with sudden onset, more severe disease, and
aggressive renal symptoms should be suspected of para-
thyroid cancer. Calcium and PTH levels tend to be much
higher than those in most patients with hyperparathy-
roidism. A palpable mass at the suspected location of a
parathyroid should be considered parathyroid cancer until
proved otherwise. An absolute preoperative diagnosis
of cancer usually cannot be made by current biopsy
techniques.
When operating on any patient for hyperparathyroid-
ism, the surgeon should be attuned to signs that the
putative adenoma is in fact a cancer. The lesion is usually
much rmer than usual and is frequently adherent to
surrounding thyroid or other tissue. It typically has a pale
gray to white color rather than the usual reddish-brown
appearance of an adenoma. Frozen section may show signs
suggestive of cancer, such as brous septations or capsular
invasion, but is usually not denitive at conrming a diag-
nosis of cancer. This tumor is sufciently rare that there
are no evidence-based guidelines to guide the extent of
resection. If parathyroid cancer is suspected, however,
41 PARATHYROID SURGERY 419
most surgeons would recommend a wide excision includ-
ing the thyroid lobe and any adjacent lymph nodes.
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tive hormone assay (QPTH) compared with the standard
bilateral neck exploration. Surgery 2000;128:
925929.
19. Arici C, Cheah WK, Ituarte PH, et al. Can localization
studies be used to direct focused parathyroid operations?
Surgery 2001;129:720729.
20. Clark PB, Case D, Watson NE, et al. Experienced
scintigraphers contribute to success of minimally invasive
parathyroidectomy by skilled endocrine surgeons. Am
Surg 2003;69:478483.
21. Pappu S, Donovan P, Cheng D, et al. Sestamibi scans are
not all created equally. Arch Surg 2005;140:383386.
22. Athanasoulis T. 11C-methionine PET versus 99mTc-
sestamibi in the pre-operative localisation of hyperfunc-
tional parathyroid tissue. Eur J Nucl Med Mol Imaging
2005;32:514.
23. Otto D, Boerner AR, Hofmann M, et al. Pre-operative
localisation of hyperfunctional parathyroid tissue with 11C-
methionine PET. Eur J Nucl Med Mol Imaging
2004;31:14051412.
24. Norman J, Chheda H. Minimally invasive parathyroidec-
tomy facilitated by intraoperative nuclear mapping.
Surgery 1997;122:9981003.
25. Irvin GL III, Solorzano CC, Carneiro DM. Quick
intraoperative parathyroid hormone assay: surgical adjunct
to allow limited parathyroidectomy, improve success rate,
and predict outcome. World J Surg 2004;28:1287
1292.
26. Irvin GL III, Dembrow V, Prudhomme DL. Clinical
usefulness of an intraoperative quick parathyroid
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27. Irvin GL III, Deriso GT III. A new, practical intraopera-
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466468.
28. Gordon LL, Snyder WH, Wians F Jr, et al. The validity of
quick intraoperative parathyroid hormone assay: an
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29. Chen H, Pruhs Z, Starling JR, et al. Intraoperative
parathyroid hormone testing improves cure rates in
patients undergoing minimally invasive parathyroidectomy.
Surgery 2005;138:583587.
30. Phillips IJ, Kurzawinski TR, Honour JW. Potential pitfalls
in intraoperative parathyroid hormone measurements
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453458.
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results of subcutaneous parathyroid grafts in uremic
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2737.
42
Adrenal Surgery
Arsalla Islam, MD, William H. Snyder, MD,
and Fiemu Nwariaku, MD
INTRODUCTION
Adrenalectomy is performed primarily for functioning
and nonfunctioning tumors of the adrenal glands. Many
technical variations have evolved since the rst description
by Thornton in 1899. Laparoscopic adrenalectomy is now
the most common type reported in the United States.
Originally described by Gagner in 1992,1 laparoscopic
adrenalectomy has dramatically reduced the lengths of
the hospital stay and of the postoperative recovery. This
chapter discusses potential pitfalls associated with adrenal-
ectomy. These misadventures can result from inappro-
priate or inadequate preoperative evaluation or a lack of
technical expertise.
Evaluation of Adrenal Masses
Given the large number of available diagnostic tests, a
focused and streamlined approach to preoperative testing
is necessary to control cost and limit patient anxiety. Two
questions are important from a surgical perspective: (1) Is
the mass biochemically functional and (2) is it malignant?
The detailed biochemical evaluation is beyond the scope
of this chapter but has been reviewed previously.1a The
clinician must exclude common functioning adrenal
tumors such as pheochromocytomas, aldosterone-produc-
ing adenomas, and cortisol-producing adenomas. A history
of hypertension, unprovoked kaliuresis, palpitations or
episodic spells associated with resistant hypertension, or
unexplained weight gain or bruising is important to deter-
mine if the adrenal mass is associated with hormone hyper-
secretion. However, biochemical testing is the standard
method of excluding hypersecretion. This should include
24-hour urinary estimation of catecholamines and their
degradation products (metanephrines), cortisol, potas-
sium, and aldosterone. The plasma aldosteronetorenin
ratio is a useful screening tool for primary hyperaldoste-
ronism, whereas the combination of 24-hour urinary free
cortisol levels and a dexamethasone suppression test can
identify cortisol hypersecretion.
The diagnosis of malignancy in an adrenal mass is much
more challenging because of the rarity of primary adrenal
cancer,2 the poor specicity of noninvasive imaging for
cancer, and the lack of reliable biomarkers to diagnose
adrenal cancer. Radiologic methods such as delayed con-
trast-enhanced computed tomography (CT) show the
most promise in estimating malignancy risk.3,4 Malignant
tumors retain intravenous contrast dye for longer periods
(e.g., there is less washout) than benign tumors. This
approach has a reported sensitivity of 88% and specicity
of 96% for the diagnosis of adenoma.5 Size is also an
important factor, and many endocrine surgeons recom-
mend adrenalectomy based on the size of adrenal
tumors.68 Investigators at a recent NIH consensus confer-
ence statement9 determined the risk of malignancy in
adrenal masses to be 2% in tumors less than 2 cm, 6% in
tumors 2 to 4 cm, and 25% in tumors greater than 4 cm.
Based on these factors, we offer the algorithm in Figure
421 for the preoperative evaluation of adrenal tumors.
INDICATIONS FOR ADRENALECTOMY
As shown in Figure 421, we recommend adrenalectomy
for biochemically functioning lesions regardless of size
and for nonfunctioning tumors larger than 4 cm or those
that increase in size during observation. The choice of
surgical approach depends on patient-related factors such
as prior abdominal surgery, comorbid conditions, and
body habitus and on tumor characteristics such as size and
invasiveness.
SPECIFIC PITFALLS IN
ADRENAL SURGERY
Radiologic Pitfalls
High-resolution CT and magnetic resonance imaging
(MRI) studies can now identify subtle radiologic abnor-
malities that may mimic adrenal masses. Such ndings
occasionally lead to inappropriate abdominal exploration.
Common mimics of adrenal tumors include renal tumors,
tortuous splenic vessels and pseudoaneurysms, accessory
spleens, pancreatic cysts, and gastric tumors. Figures 422
to 424 show examples of such lesions.
 422 SECTION V: ENDOCRINE SURGERY

Asymptomatic
Patient with Incidental
Adrenal Mass

Biochemical testing
Elevated 24 hr UFC, +
Adrenalectomy
Positive low dose dex
suppression, size > 4cm
Elevated aldo-renin ratio
Elevated plasma and/or Interval growth or
urinary metanephrines. hyperfunction

Non-enhanced CT <10 Surveillance A

>10H

>50% contrast
washout (15min)
Delayed enhanced CT or OR
chemical shift MRI signal drop on
out-of-phase MRI

<50% contrast
washout OR
NO signal drop
on out-of-

Adrenalectomy
B
Figure 421 Algorithm for the preoperative evaluation of adrenal Figure 423 Varix mimicking adrenal tumor on CT scan.
tumors.

Figure 422 Gastric fundus mass can mimic adrenal tumor on Figure 424 Accessory spleen.
computed tomography (CT) scan.

Consequence images by an experienced radiologist can reduce errors

Eagerness to perform surgery on such patients
without appropriate evaluation can result in unneces-
sary procedures.
Prevention
Multiphase, thin-section (35 mm) CT scan is most
useful. Density measurements and examination of the
in diagnosis. Figures 425 and 426 show CT images
of adrenal long limb variant and metastasis of the
adrenal gland, respectively.
Biochemical Pitfalls
The full scope of biochemical evaluation of patients with
adrenal masses is beyond the scope of this chapter.

Figure 425 Adrenal long limb variant.
Figure 426 Adrenal metastasis shown on CT scan.
However, the minimal evaluation should include measure-
ment of plasma aldosterone concentration and renin
activity, plasma or 24-hour urinary metanephrines, and
24-hour urinary free cortisol.
Consequence
Unnecessary surgical procedures.
Intraoperative hemodynamic instability can be fatal for
patients undergoing adrenalectomy for pheochromocy-
toma who have not undergone appropriate preoperative
adrenergic blockade.
Prevention
The use of rigorous criteria to conrm biochemical
hyperfunction can reduce errors in diagnosis.
Pheochromocytoma
Adequate preoperative adrenergic blockade may be the
single most important factor in reducing perioperative
42 ADRENAL SURGERY 423
morbidity and death during the surgical treatment of
pheochromocytoma. Conversely, inadequate -adrenergic
blockade can result in perioperative cardiovascular mor-
bidity and death. We use selective 1-adrenergic receptor
antagonists such as phenoxybenzamine and doxazosin 1
to 3 weeks prior to surgery. This may be supplemented
with -adrenergic blockade for patients who develop
tachycardia or cardiac arrhythmia during -adrenergic
blockade. Intravascular volume depletion in patients with
pheochromocytoma is the result of persistent vasoconstric-
tion. Therefore, preoperative volume expansion is neces-
sary to avoid profound perioperative hypotension.
Cortisol-Secreting Adrenal Tumors
Patients with cortisol hypersecretion have a fourfold
increased risk of thromboembolic complications com-
pared with the general population.10 Therefore, throm-
bosis prophylaxis with low-dose heparin and pneumatic
leg compression devices is particularly important in these
patients. Perioperative steroids may be required to prevent
hypotension after unilateral adrenalectomy and denitely
after bilateral resection.
Nelsons syndrome is a complication of bilateral total
adrenalectomy for Cushings disease. It may occur in up
to 30% of such patients and manifests as progressive
pituitary enlargement and cutaneous pigmentation from
increased adrenocorticotropic hormone (ACTH) hyperse-
cretion. Pituitary irradiation may limit the progression of
Nelsons syndrome in selected patients.
Aldosterone-Producing Adenomas
Correction of hypokalemia with oral potassium chloride
in patients with Conns syndrome is necessary to prevent
cardiac arrhythmias during general anesthesia.
OPERATIVE APPROACHES
Operative approaches for open adrenalectomy include
the anterior (transperitoneal), ank (extraperitoneal),1113
posterior (retroperitoneal),14 thoracoabdominal, and
transdiaphragmatic approaches. We restrict this discussion
to the common approaches including anterior trans-
peritoneal and posterior retroperitoneal operations.
Anterior Transperitoneal Approach
Advantages
Surgeon familiarity with anatomic landmarks.
Evaluation and surgical therapy of coexisting intraperi-
toneal diseases.
Contraindications and Disadvantages15,16
Extensive intra-abdominal adhesions due to prior intra-
abdominal surgery or infection.
High potential for bowel injury and postoperative
ileus.
 424 SECTION V: ENDOCRINE SURGERY

Advantages
Posterior Retroperitoneal Approach Better en-bloc resection and lymphatic clearance for
Advantages malignant tumors.
Avoids peritoneal adhesions due to prior intra-
abdominal surgery or infection. Disadvantages
Less postoperative ileus and lower risk for bowel More postoperative ileus compared with laparoscopic
injury. approach.

Retroperitoneal AdrenalectomyPosterior
Contraindications and Disadvantages
Smaller operating space limits manipulation and exci-
Approach
sion of large tumors. Advantages
Few landmarks for the surgeon. Reduced operative time for bilateral adrenalectomy.
Previous renal/perirenal surgery. Fewer wound complications than with the open retro-
Retroperitoneal brosis. peritoneal approach.
Severe scoliosis.11,14
Disadvantages
Limited operative space.
Laparoscopic Transperitoneal Adrenalectomy Poor organ and tissue landmarks.
Indications Requires specic experience.
Benign tumors, whether or not functional.
Bilateral adrenal hyperplasia.
Selected solitary adrenal metastases.
Open Posterior Adrenalectomy
Advantages
Contraindications Bilateral adrenalectomy without the need to reposition
Adrenal tumors more than 10 cm in size.17 the patient.
Adrenal cancers and other malignant adrenal tumors. Less postoperative ileus.
Fewer wound complications.
Advantages
Fewer wound complications.18,19 Disadvantages
Decreased hospital stay and postoperative analgesia Less visualization and control of potential
requirement.19 hemorrhage.
Faster return of normal bowel function.20 Difcult dissection with larger tumors (>7 cm).
Decreased transfusion requirements. The adrenal vein is identied at a later phase in dissec-
Improved patient comfort and satisfaction and early tion. Therefore, pheochromocytomas are a relative
return to normal daily activities. contraindication because early ligation of the adrenal
vein may prevent excessive intra-operative hemody-
namic instability.
Open Transperitoneal Adrenalectomy
Subcostal nerve injury.
Indications
Large tumors (>68 cm).
Malignant tumors, particularly with evidence of
Thoracoabdominal Adrenalectomy
invasion. Indications
Conversion to open procedure during a laparoscopic Tumors greater than 12 cm.
approach.21 Tumors adherent to the diaphragm, liver, and extra-
Primary or metastatic invasive adrenal malignancies adrenal structures.
because extensive en-bloc excision and node dissection
may be necessary. Advantages
Previous extensive upper abdominal surgery in the area Excellent exposure for large tumors.
of adrenal dissection (e.g., nephrectomy, partial hepa-
tectomy, or splenectomy). Disadvantages
Intracranial hypertension (may be exacerbated by CO2 Postoperative pulmonary dysfunction. Division of the
insufation). diaphragm peripherally, 2 cm from its insertion into
Diaphragmatic hernias. the chest wall, may reduce postoperative pulmonary
Cardiovascular and respiratory diseases that preclude dysfunction.
laparoscopic surgery. Postoperative pain.
 42 ADRENAL SURGERY 425

Step 7 Dissection of inferior pole of adrenal gland and

Laparoscopic Anterior superior pole of kidney
Step 8 Removal of adrenal gland and desufation
Transperitoneal Step 9 Closure of trocar sites

Adrenalectomy Positioning
OPERATIVE STEPS (Table 421) Figure 428 shows the positioning for the laparo-
scopic anterior transperitoneal approach during right
Step 1 Positioning adrenalectomy.
Step 2 Trocar insertion and CO2 insufation
Step 3 Liver mobilization (spleen and pancreas for left Nerve Injuries; Brachial Plexus, Peroneal
adrenal gland) Nerve Injury
Step 4 Dissection of inferior vena cava (IVC)
Step 5 Identication and ligation of adrenal vein Consequence
Step 6 Dissection of arterial supply (medial) of adrenal Transient or permanent neuropathy with disability.
gland Grade 1/3 complication

Table 421 Steps for Laparoscopic Anterior Repair

Transperitoneal Adrenalectomy No specic repair. Physical therapy and rehabilitation
may improve function.
Step Description
Prevention
Position of the Full left lateral decubitus position, lower leg
patient exed, cushion under left ank, table exed to
Padding of all bony prominences, especially the depen-
open the space between the inferior costal dent lower extremity. Correct placement of axillary roll
margin and the anterior superior iliac spine.

Trocar Usually three or four trocars (one 12 mm and

placement three 5 mm) and a 30 laparoscope are
required.

Liver retraction An atraumatic liver retractor is used to gently

retract the liver superiorly and medially.

Mobilization of Using electrocautery hook, scissors, or ultrasonic

the liver shears, the subhepatic peritoneum is incised
(spleen and lateral to the inferior vena cava. Complete
pancreas for mobilization of the liver to include dissection of
left adrenal) the right triangular ligament.

Identication of Lateral border of the inferior vena cava is

the inferior dissected superiorly to the level of the right
vena cava and crus of the diaphragm and can be dissected
the renal vein inferiorly to visualize the renal vein.

Identication of Main adrenal vein is divided between surgical

the main and clips. An accessory adrenal vein may be present
accessory inferiorly. Figure 427 Placement of the adrenal gland in an Endobag.
adrenal veins

Dissection of Multiple adrenal arteries supply the adrenal gland

the arteries from the aorta and the phrenic and renal
arteries. These can usually be controlled by
electrocautery or with ultrasonic shears.

Extraction of Attachments between the inferior aspect of the

the gland gland and the upper pole of the kidney are
dissected. The gland is grasped with an
atraumatic grasper and introduced into an
extraction bag. The port site may be slightly
enlarged depending on the size of the gland.
Figure 427 shows placement of adrenal gland
in an endobag.

Postoperative Liquid diet and ambulation on the day of surgery.

Figure 428 Position for the laparoscopic right adrenalectomy
care Discharge home in 1 or 2 days.
transperitoneal approach.
 426 SECTION V: ENDOCRINE SURGERY
prior to laparoscopic adrenalectomy. Avoidance of
excessive shoulder stretching. The lower leg is slightly
exed to provide stability and the upper leg extended.
A pillow placed between the legs should support the
upper leg and prevent stress on the knee joint.
Skeletal Fractures May Occur with Patients with
Severe Osteoporosis from Cushings Syndrome
Consequence
Inability to ambulate.
Grade 4 complication
Repair
Open reduction and internal xation.
Prevention
Padding of all bony prominences and preventing exces-
sive torsion on joints.
Trocar Insertion and CO2 Insufation
Figure 429 shows port placement from above.
Bowel and Vascular Injuries
Grade 3 complication
Bowel and vascular injuries during entry into the abdomen
may occur during laparoscopic procedures. Their conse-
quences and steps for prevention are detailed in Section
I, Chapter 7, Laparoscopic Surgery.
Liver Mobilization (Spleen and Pancreas for
Left Adrenal Gland)
Solid Organ Injury
Consequence
Bleeding (intraoperative and postoperative). May
require open conversion and splenorrhaphy or splenec-
tomy. Pancreatic stula and intra-abdominal abscess
formation.
Grade 3 complication
Figure 429 Trochar placement for laparoscopic right
adrenalectomytransperitoneal approach.
Repair
Intraoperative repair when possible. Control of bleed-
ing with energy sources (electrocautery, argon beam
coagulator) or hemostatic agents. May require open
conversion.
Prevention
Careful dissection, leaving a peritoneal ap during
splenic or liver dissection.
Dissection of the IVC and Adrenal Vein
Vascular Injury (IVC, Renal or Adrenal Vein)
Consequence
Intraoperative bleeding and hypotension. Renal
ischemia or infarction with possible renal loss.
Grade 3 complication
Repair
Small tears may be controlled with surgical clips. Larger
tears will require open conversion and suture repair.
Direct gentle caval compression may be attempted with
an endoscopic Kittner dissector during a laparoscopic
procedure to control blood loss. Conversion to open
adrenalectomy should be performed early if there is
difculty maintaining hemostasis.
Prevention
Careful dissection with minimal tension on the adrenal
gland or adrenal vein. Clear visualization of the space
between the IVC and the right adrenal gland. The right
adrenal vein drains directly into the right hepatic vein
in 4% of patients.22 An accessory right adrenal vein can
also drain into the inferior phrenic vein, and rarely, the
main adrenal vein can divide into two branches, each
entering the IVC separately.
Identication and Ligation of the Adrenal Vein
Adrenal Vein Injury
Consequence
Same as for Vascular Injury (IVC, Renal or Adrenal
Vein), earlier. An example of adrenal hemorrhage
from possible adrenal vein injury during adrenal vein
sampling is shown in Figure 4210.
Grade 3 complication
Figures 4211 and 4212 show adrenal vein and its
relation to inferior vena cava.
Dissection of the Arterial Supply (Medial) to
the Adrenal Gland
Bleeding from Adrenal Arteries
Consequence
Intraoperative or postoperative hemorrhage.
Grade 3 complication
 42 ADRENAL SURGERY 427

Figure 4213 Partial diaphragmatic injury.

Figure 4210 Adrenal hemorrhage.

IVC

Repair
Control of small adrenal arteries can usually be accom-
plished with surgical clips. The use of a suction irriga-
tor device as a retractor is helpful to keep the operative
eld dry.
Prevention
Adrenal Careful use of ultrasonic shears or electrocautery to
vein
coagulate small arteries prior to dividing them.

Injury to the Diaphragm or Stomach

(Left Adrenalectomy)
Figure 4211 Adrenal vein going into the inferior vena cava Consequence
(IVC).
Postoperative bleeding. Postoperative abdominal
abscess. Gastrocutaneous stula. Diaphragmatic hernia.
Figure 4213 shows diaphragmatic injury during lapa-
roscopic right adrenalectomy.
Grade 3 complication
Repair
Laparoscopic or open suture repair of the stomach or
diaphragm.
Prevention
Sharp dissection under direct vision.

Clips on
adrenal vein Dissection of the Inferior Pole of the Adrenal
IVC Gland and the Superior Pole of the Kidney
Renal Vascular Injury
Consequence, Repair, and Prevention
Similar to those of Vascular Injury (IVC, Renal or
Adrenal Vein), earlier.
Figure 4212 Clipped adrenal veinright adrenalectomy. Grade 3 complication
 428 SECTION V: ENDOCRINE SURGERY

Removal of the Adrenal Gland Duodenal Injury

Hollow Viscus or Solid Organ Injury
Consequence
Consequence and Repair Duodenal stula. Abscess formation.
Same as for Bowel and Vascular Injuries, and Solid Grade 3 complication
Organ Injury, under Liver Mobilization (Spleen and
Pancreas for Left Adrenal Gland), earlier. Repair
Grade 3 complication Two-layer suture repair and drainage.

Prevention Prevention
Direct visualization of the bag during extraction from Dissecting the IVC cephalad to the duodenum.
the abdominal cavity will prevent the bowel being
pulled up and injured during removal of the adrenal
Colonic Injury (Hepatic Flexure)
gland.
Consequence, Repair, and Prevention
This is rare during right adrenalectomy; however,
Closure of Trocar Sites the consequences and repair are similar to those of
Similar to that for other laparoscopic procedures. Bowel and Vascular Injuries under Laparoscopic
Entrapped bowel and postoperative hernias may occur; Anterior Transperitoneal Adrenalectomy, earlier.
therefore, closure of trocar sites should be performed Figures 4214 and 4215 show the laparoscopic dis-
under direct vision (laparoscopically or anteriorly). section for a right adrenalectomy. Figure 4216 shows
the mobilization of the liver in an open approach.
Grade 3 complication
Open (Right) Anterior
Adrenalectomy
Open (Left) Anterior
OPERATIVE STEPS
Adrenalectomy
Step 1 Entering abdomen
Step 2 Mobilizing liver OPERATIVE STEPS
Step 3 Dissection of IVC
Step 4 Identication and ligation of adrenal vein Step 1 Entering abdomen
Step 5 Dissection of arterial supply (medial) of adrenal Step 2 Entering lesser sac and mobilizing pancreas
gland Step 3 Identication and ligation of adrenal vein
Step 6 Dissection of inferior pole of adrenal gland and Step 4 Dissection of arterial supply (medial) of adrenal
superior pole of kidney gland
Step 7 Removal of adrenal gland Step 5 Dissection of inferior pole of adrenal gland
Step 6 Removal of adrenal gland

Abdominal Entry
Abdominal Entry
Small Bowel Injury
Bowel Injury
Consequence, Repair, and Prevention
Similar to consequences during Laparoscopic Anterior Consequence, Repair, and Prevention
Transperitoneal Adrenalectomy, earlier. In the pres- Same as those of Bowel and Vascular Injuries under
ence of adhesions, sharp dissection under direct vision Laparoscopic Anterior Transperitoneal Adrenalec-
may reduce the risk of bowel injury. tomy, earlier.
Grade 3 complication Grade 3 complication

Hepatic Flexure Injury Entering the Lesser Sac and Mobilizing

Consequence, Repair, and Prevention
the Pancreas
Similar to those of Bowel and Vascular Injuries under Stomach Injury
Laparoscopic Anterior Transperitoneal Adrenalec- Same as those of Bowel and Vascular Injuries under
tomy, earlier. Laparoscopic Anterior Transperitoneal Adrenalectomy,
Grade 3 complication earlier.
 42 ADRENAL SURGERY 429

Liver

Figure 4215 Dissectionright adrenalectomy.

Adrenal

Kidney

Figure 4216 Mobilization of the liver for a right

adrenalectomy.

Prevention
Gentle upward retraction of the pancreas with blunt
retractors.

Colonic Injury (Splenic Flexure)

Consequence, Repair, and Prevention
Similar to those of Bowel and Vascular Injuries under
Laparoscopic Anterior Transperitoneal Adrenalec-
C tomy, earlier.
Figure 4214 Dissectionright adrenalectomy. Grade 3 complication

Splenic Injury
Pancreatic Injury
Consequence
Pancreatic stula or abscess. Pancreatitis.
Grade 3 complication
Repair
No repair for small injuries. However, larger injuries
may require distal pancreatectomy. All injuries should
be drained to create a controlled pancreatic stula.
Consequence
Intraoperative or postoperative hemorrhage requir-
ing splenorrhaphy or splenectomy. Postsplenectomy
infection.
Grade 4 complication
Repair
Electrocautery, argon beam coagulator, hemostatic
agents, splenorrhaphy. or splenectomy.
 430 SECTION V: ENDOCRINE SURGERY

Prevention Step 3 Retroperitoneal entry

Sharp dissection of splenocolic and splenophrenic liga- Step 4 Dissection of upper pole of kidney
ments under direct vision and leaving a ap of perito- Step 5 Dissection of arterial supply (medial) of adrenal
neum attached to the spleen during dissection. This gland
ap can be used to retract the spleen without avulsing Step 6 Ligation of adrenal vein
the splenic capsule. Step 7 Removal of adrenal gland
Step 8 Wound closure
Identication and Ligation of the Adrenal Vein
Patient Positioning
Discussed under Laparoscopic Anterior Transperitoneal
Adrenalectomy under Dissection of the IVC & Adrenal Patient is placed prone with arms extended. There is a risk
Vein. of brachial plexus injury from stretching, especially in
prolonged cases.
Dissection of the Arterial Supply (Medial) of
the Adrenal Gland Incision Placement and Muscle Dissection
Injury to thoracic duct or intestinal lymphatics around the The classic Young curvilinear (hockey-stick) incision or a
left crus may occur. 12th rib incision (parallel to the 12th rib) may be used.
Injury to the Lymphatics
Rib Resection and Pleural Reection
Consequence
Injury to the Intercostal Blood Vessels and
Chylous stulas.
the Subcostal Nerve
Grade 3 complication
Consequence
Repair Intraoperative or postoperative hemorrhage. Retro-
Initial therapy is pharmacologic. Etilefrine chlorhydrate peritoneal hemorrhage. Postoperative abdominal wall
is an -adrenergic agonist that acts on the muscular hypesthesia and muscle laxity.
bers of the thoracic duct. Patients can also be placed Grade 2 complication
on a medium chain triglyceride diet. Persistent chylous
stulas may require reoperation. Repair
Suture ligation of intercostal blood vessels. No repair
Prevention for nerve injury.
Dilated lymphatic connections should be individually
ligated. Prevention
Subperiosteal dissection prior to rib resection ensures
Dissection of the Inferior Pole of the that only the rib is resected.
Adrenal Gland
Injury to the Pleura
Complications and pitfalls are similar to those of laparo-
scopic anterior transperitoneal adrenalectomy under Dis- Consequence
section of the Inferior Pole of the Adrenal Gland and Pneumothorax. Lung injury.
Superior Pole of the Kidney. Grade 3 complication

Repair
Removal of the Adrenal Gland Suture repair and thoracostomy tube drainage.
Complications and pitfalls are as discussed under Removal
of the Adrenal Gland under Laparoscopic Anterior Prevention
Transperitoneal Adrenalectomy. Subperiosteal dissection.

Dissection of the Upper Pole of the Kidney

Open Posterior Injury to the Kidney, Hemorrhage
Adrenalectomy Consequence
Intraoperative or postoperative hemorrhage.
OPERATIVE STEPS Grade 3 complication

Step 1 Patient positioning Repair

Step 2 Incision placement and muscle dissection Hemostasis with ligatures and electrocautery.
 42 ADRENAL SURGERY 431

Fascial
edge

Phrenic
vein
Lumbar Lumbar
hernia hernia

Adrenal
vein

Figure 4218 Bilateral lumbar hernias after an open posterior

adrenalectomy.

Prevention
Use of the kidney for retraction and avoidance of exces-
sive traction on the adrenal vein.

Wound Closure
Figure 4217 Left adrenaldissection showing the conuence
of adrenal and phrenic veins. Lumbar Hernias (Fig. 4218)
Consequence
Prevention Pain and discomfort.
Sharp dissection under direct vision. Grade 3 complication
Dissection of the Arterial Supply (Medial) to
Repair
the Adrenal Gland
Operative hernia repair.
Complications are similar to those of Dissection of the
Arterial Supply (Medial) to the Adrenal Gland under Prevention
Laparoscopic Anterior Transperitoneal Adrenalectomy, Multilayer closure with nonabsorbable or delayed
earlier. absorbable sutures.
Ligation of the Adrenal Vein
Complications are similar to those of Dissection of the Retroperitoneoscopic
Arterial Supply (Medial) to the Adrenal Gland under
Laparoscopic Anterior Transperitoneal Adrenalectomy, (Posterior)
earlier.
Adrenalectomy
Injury to the Vena Cava or the Renal Vein
Figure 4217 shows the left adrenal vein and the phrenic OPERATIVE STEPS
vein.
Step 1 Patient positioning
Consequence Step 2 Incision placement and muscle dissection
Intraoperative or postoperative hemorrhage. Renal Step 3 Retroperitoneal entry
injury. Step 4 Dissection of upper pole of kidney
Grade 3 complication Step 5 Dissection of arterial supply (medial) of adrenal
gland
Repair Step 6 Ligation of adrenal vein
Suture repair with monolament nonabsorbable Step 7 Removal of adrenal gland
suture. Step 8 Wound closure
 432 SECTION V: ENDOCRINE SURGERY
Figure 4219 Stapler for partial adrenalectomy.
The complications of this approach are similar to those
that occur after Open Posterior Adrenalectomy.
However, the incidence of wound complications is
lower.23,24
Partial adrenalectomy may be necessary in situations in
which preservation of adrenal function is desirable in a
patient with no contralateral adrenal gland. The challenge
of partial adrenalectomy is parenchymal bleeding and
remnant devascularization. However, these can be mini-
mized using careful dissection, bipolar electrocautery, and
topical hemostatic agents. Stapling devices can also be
used for partial resections (Fig. 4219).
REFERENCES
1. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalec-
tomy in Cushings syndrome and pheochromocytoma. N
Engl J Med 1992;327:1033.
1a. Brunt LM. Current approach to the adrenal inciden-
taloma. In Problems in General Surgery. Philadelphia:
Lippincott, 1984; pp 8191.
2. Suzuki H. Laparoscopic adrenalectomy for adrenal
carcinoma and metastases. Curr Opin Urol 2006;16:47
53.
3. Caoili EM, Korobkin M, Francis IR, et al. Delayed
enhanced CT of lipid-poor adrenal adenomas. AJR Am J
Roentgenol 2000;175:14111415.
4. Boland GW, Hahn PF, Pena C, et al. Adrenal masses:
characterization with delayed contrast-enhanced CT.
Radiology 1997;202:693696.
5. Anca M, Avram LMF, Gross MD. Adrenal gland scintigra-
phy. Semin Nucl Med 2006;36:212227.
6. Favia G, Lumachi F, Basso S, et al. Management of
incidentally discovered adrenal masses and risk of malig-
nancy. Surgery 2000;128:918924.
7. Korobkin M, Dunnick NR. Characterization of adrenal
masses. AJR Am J Roentgenol 1995;164:643644.
8. Outwater EK, Siegelman ES, Radecki PD, et al. Distinc-
tion between benign and malignant adrenal masses: value
of T1-weighted chemical-shift MR imaging. AJR Am J
Roentgenol 1995;165:579583.
9. NIH state-of-the-science statement on management of the
clinically inapparent adrenal mass (incidentaloma). NIH
Consens State Sci Statements 2002;19:125.
10. Small M, Lowe GDO, Forbes CD, et al. Thromboembolic
complications in Cushings syndrome. Clin Endocrinol
1983;19:503511.
11. Bonjer HJ, Bruning HA. Endoscopic retroperitoneal
ank approach. Oper Tech Gen Surg 2002;4:322330.
12. Hanssen WE, Kuhry E, Casseres YA, et al. Safety and
efcacy of endoscopic retroperitoneal adrenalectomy. Br J
Surg 2006;93:715719.
13. Berends FJ, Harst EVD, Giraudo G, et al. Safe retroperi-
toneal endoscopic resection of pheochromocytomas.
World J Surg 2002;26:527531.
14. Berber E, Siperstein AE. Laparoscopic retroperitoneal
adrenalectomyposterior approach. Oper Tech Gen Surg
2002;4:331337.
15. Brunt LM, Doherty GM, Norton JA, et al. Laparoscopic
adrenalectomy compared to open adrenalectomy for benign
adrenal neoplasms. J Am Coll Surg 1996;183:110.
16. Saunders BD, Doherty GM. Laparoscopic adrenalectomy
for malignant disease. Lancet Oncol 2004;5:718726.
17. Shen W, Sturgeon C, Clark OH, et al. Should pheochro-
mocytoma size inuence surgical approach? A comparison
of 90 malignant and 60 benign pheochromocytomas.
Surgery 2004;136:11291136.
18. Gagner M. Laparoscopic adrenalectomy. Surg Clin North
Am 1996;76:523537.
19. Gagner M, Pomp A, Heniford BT, et al. Laparoscopic
adrenalectomy: lessons learned from 100 consecutive
procedures. Ann Surg 1997;226:238246; discussion
246247.
20. Fazeli-Matin S, Gill IS, Hsu THS, et al. Laparoscopic
renal and adrenal surgery in obese patients: comparison to
open surgery. J Urol 1999;162:665669.
21. Shen W, Kebebew E, Clark O. Reasons for conversion
from laparoscopic to open or hand-assisted adrenalectomy:
review of 261 laparoscopic adrenalectomies from 1993 to
2003. World J Surg 2004;28:11761179.
22. Proye CAG, Lokey JS. Thoracoabdominal adrenalectomy
for malignancy. Oper Tech Gen Surg 2002;4:338345.
23. Walz MK, Alesina PF, Wenger FA, et al. Laparoscopic and
retroperitoneoscopic treatment of pheochromocytomas
and retroperitoneal paragangliomas: results of 161 tumors
in 126 patients. World J Surg 2006;30:899908.
24. Walz MK, Petersenn S, Koch JA, et al. Endoscopic
treatment of large primary adrenal tumours. Br J Surg
2005;92:719723.
Section VI
BREAST SURGERY
Shawna C. Willey, MD
It is on our own failures that we base a new and different and better success.
Havelock Ellis
43
Image-Guided Breast Biopsy
Richard E. Fine, MD and Kenneth J. Bloom, MD
INTRODUCTION
Increased utilization of mammography screening is
believed to have resulted in a relative increase in breast
abnormalities of sufcient risk to warrant a biopsy. It is
estimated that approximately 1.5 million breast biopsies
are performed each year in the United States. Many of
these biopsies are for nonpalpable lesions and, therefore,
require some type of image guidance. A signicant number
of these biopsies will be performed for benign disease
because the average positive predictive value for mam-
mography is only 20% (range 15%35%).14 If traditional
methods for histologic conrmation were utilized, all
women with nonpalpable breast lesions would proceed to
the operating room after a wire localization procedure was
performed in the radiology suite. Percutaneous image-
guided breast biopsy has become an effective minimally
invasive alternative to open surgical breast biopsy for the
diagnosis of both palpable and nonpalpable image-
detected abnormalities.57 Although the risk of bleeding
and infection may be comparable with those of open sur-
gical breast biopsy, some potential difculties are unique
to image-guided breast biopsy.8
With the early introduction by the Karalinski Institute
in 1989 of stereotactic-guided ne-needle aspiration
cytology of nonpalpable breast abnormalities,9 image-
guided percutaneous breast biopsy has been shown to
provide a secondary level of screening in a less-invasive,
cost-effective manner to obtain a histologic diagnosis
without sacricing accuracy.57,10 The evolution of the
biopsy tools used with image guidance (stereotaxic, ultra-
sound, and recently, magnetic resonance imaging [MRI])
has added to the accuracy of minimally invasive image-
guided breast biopsy,11,12 keeping a greater portion of
women with probably benign disease out of the operating
room for a diagnostic procedure. However, advancement
in technology has also added to the potential procedural
risks.13
INDICATIONS
Almost any palpable or nonpalpable, indeterminate breast
abnormality, which is visualized with imaging modalities
(ultrasound, mammography, MRI), can be evaluated with
image-guided breast biopsy. The lesions will fall into the
following categories established by the American College
of Radiology (ACR) lexicon14:
BI-RADS 3 (probably benign, short-interval follow-up
[6 mo], <2% risk of malignancy) abnormalities identi-
ed in a patient with a strong family history, difcult
clinical and imaging examination, or a high level of
anxiety.
BI-RADS 4 (suspicious abnormality, biopsy should be
considered) abnormalities, which require biopsy, may
 434 SECTION VI: BREAST SURGERY
avoid a trip to the operating room for an abnormality
with perhaps only a 20% risk of malignancy.
BI-RADS 5 (highly suggestive of malignancy, appro-
priate action should be taken) abnormalities can
provide a histologic diagnosis for preoperative patient
consultation.
Stereotactic Breast
Biopsy
Stereotaxis mammography determines the position of a
nonpalpable breast abnormality by utilizing computerized
triangulation of the targeted lesion visualized with two
stereo images, separated by a 30 arc.5,15 The equipment
for performing a stereotactic breast biopsy is either a
dedicated prone table or an add-on unit, which utilizes
a targeting and biopsy platform attached to a standard
upright mammogram system.15,16 Add-on stereotactic
breast biopsy units have been traditionally less popular
because the upright patient position and patient visualiza-
tion of the procedure have the potential for producing
increased syncopal episodes.5,17 The advantages of the
prone position include gravity to assist the technologist
with posterior lesions and a greatly enhanced workspace
beneath the table.18 Both are important for positioning
and access, which limit many of the potential difculties
in achieving a successful biopsy.
OPERATIVE STEPS
Step 1 Evaluate mammogram and lesion as well as
patient and choose image approach to breast
(craniocaudal [CC], mediolateral [ML], latero-
medial [LM])
Step 2 Position patient on stereotactic biopsy table for
visualization of image-detected abnormality
Step 3 Obtain scout and stereotactic digital images
Step 4 Target lesion on stereo images
Step 5 Anesthetize skin and breast parenchyma and
make skin incision after appropriate antiseptic
skin preparation
Step 6 Insert biopsy device based on calculated
coordinates
Step 7 Assess appropriate alignment between lesion and
biopsy device on prebiopsy and/or postbiopsy
alignment stereo digital images
Step 8 Adequately sample lesion for diagnosis and/or
potential therapeutic removal
Step 9 Place postprocedure marker and obtain
postprocedure/clip placement stereo images
Step 10 Obtain specimen radiograph
Step 11 Obtain adequate hemostasis and apply appropri-
ate dressing and/or wrap
Step 12 Check pathology for concordance with radio-
logic impression
Step 13 Obtain follow-up imaging
OPERATIVE PROCEDURE
Evaluating the Mammogram and the Patient
and Choosing the Approach to the Breast
Choosing an Inappropriate Mammogram Lesion
Type for Biopsy
Consequence
It is important to anticipate that some patients and
some lesions will be difcult to biopsy. The character-
istics of certain lesions (low-density nodules, faint
microcalcications, and vague asymmetrical densities)
make them more difcult to visualize with digital
imaging despite postprocessing features. Also, when
the eld of view of the breast is limited to a 5 5-cm
area (the size of the biopsy window in the front com-
pression paddle), the abnormality is not visualized in
relation to the remainder of the breast as it is on
the mammogram. An asymmetrical density may repre-
sent only a summation shadow of overlapping bro-
glandular tissue. Loosely clustered calcications may
become more diffuse on stereo images and be impos-
sible to target with any certainty because of varying
depth.
Grade 2 complication
Prevention
Recognizing these demanding lesions may avoid unnec-
essary scheduling and the possibility of procedures
being canceled. Complete diagnostic workup, includ-
ing spot compression views and possibly ultrasound for
asymmetrical densities and microfocus magnication
for microcalcication, is essential. A true lateral (90)
view may successfully demonstrate tea cup calcica-
tions associated with milk of calcium, in which
benign calcium deposits layer out within microcysts. It
is sometimes prudent to send patients with a complete
diagnostic evaluation and a persistent but questionable
imaging abnormality to the stereotactic suite ahead of
time to see whether the lesion can be successfully
visualized.
Failure to Recognize Patient Characteristics that
Will Result in an Unsuccessful Stereotactic
Breast Biopsy
Consequence
There are also patient characteristics that will interfere
with the success of a stereotactic breast biopsy. Patients
with neurologic or musculoskeletal conditions may not
tolerate positioning on the already-uncomfortable ste-
reotactic biopsy table. Any condition that increases the

likelihood of patient movement will cause a greater risk
of missing the target lesion. This includes patients with
acute or chronic respiratory conditions with associated
coughing and patients with a high level of anxiety,
especially those suffering from claustrophobia or ago-
raphobia. A history of bleeding abnormalities or use of
anticoagulants, as with any biopsy, creates the potential
for bleeding and complications such as hematoma.
Grade 2 complication
Prevention
When recognizing the kyphotic patient or those who
may not tolerate the table positioning, it is helpful to
ask the patient to try lying on the oor at home, with
her head turned to one side for approximately 20 to
Failure to Recognize the Position of the Lesion
30 minutes. Having cough suppressants available will
in the Breast
deal with most respiratory conditions. Although most
stereotactic breast biopsies are performed with only
local anesthesia, it may be helpful to use a diazepam
for sedation in those anxious patients. If time allows,
schedule the biopsy after 10 days of restriction from
anticoagulants working on platelet function and allow
for the reversal of warfarin. However, because the
patient facing a possible diagnosis of breast cancer may
not want to wait 10 days or if reversal of warfarin is
medically inadvisable, most procedures can still be
accomplished with only marginal risk. Using a smaller-
gauge biopsy device and wrapping the patient with a
pressure-style dressing may be helpful.
Not Choosing the Ideal Approach to the Breast
Consequence
The shortest skin-to-lesion distance and the ability to
clearly visualize the imaged abnormality are both factors
the technologist and physician consider when working
together to choose the correct approach (CC, LM,
ML, and with the Hologic Multi-Care Platinum table,
Failure to Visualize the Lesion on Both
caudocranial) to the breast. Once the shortest skin-to-
Stereo Images
lesion distance is chosen, the lesion must be well visu-
alized. The visibility of the breast abnormality may
occasionally take priority over the shortest distance
from the skin to the lesion. Although a lesion in the
breast at 12 oclock may suggest a CC approach, if the
lesion is seen better on the patients mediolateral
oblique (MLO) mammogram view, then an ML approach
may be preferable. A situation may arise (on the Fischer
Mammotest table) in which the abnormality is best seen
in the CC view but the lesion appears to be in the inferior
aspect of the breast on the MLO mammogram view.
Therefore, it may not be possible to insert the biopsy
instrument without traversing most of the breast tissue
and striking the back of the patients breast (negative
stroke margin), because in contrast to the Hologic
Multicare Platinum table, the Fischer Mammotest table
does not provide a caudocranial approach.
Grade 1 complication
43 IMAGE-GUIDED BREAST BIOPSY 435
Repair/Prevention
Determining the true position of the lesion within the
breast starts with an understanding of the virtual posi-
tion of the lesion created by the usual 60 MLO mam-
mogram. A lesion that is in the lateral breast appears
to be higher on the MLO view than its true position
and a medial lesion appears lower on the MLO view
than its true position. Therefore, if the patients abnor-
mality is visualized best in the CC view, but the lesion
is in the medial aspect of the breast, the biopsy using
this approach will be successful and may not impale the
underside of the breast because the medial lesion is
actually more superior in the breast than it is perceived
on the MLO mammogram view.
Consequence
The technologist may have difculty in locating a lesion
for biopsy when positioning the patient on the stereo-
tactic table if the correct position of the lesion in the
breast is not appreciated.
Grade 1 complication
Repair
Remember that when positioning a patient on a prone
stereotactic table for an LM or ML approach that this
is a 90 angle to the breast compared with the 60
angle associated with the traditional MLO mammo-
gram view. Therefore, the lesion in the lateral aspect of
the breast will move to a more inferior position with
the LM stereotactic approach compared with its appar-
ent position on the MLO mammogram. A lesion in
the medial aspect of the breast will move to a more
superior position with an ML (90) stereotactic
approach compared with its apparent position on the
MLO mammogram.
Consequence
When a lesion well visualized on the scout image lacks
visibility on both stereo images, another difculty arises,
especially when the physician has already considered
the shortest skin-to-lesion distance and the clarity of
the image on each mammogram view. This is most
often due to broglandular tissue that superimposes
itself over the target lesion in one of the stereo images
because of the angle of exposure.
Grade 1 complication
Repair
A technique known as target on scout can be utilized
to resolve the issue of limited clarity of the lesion on
one of two stereotactic images. The stereo image, with
poor lesion visibility, is replaced by the original scout
image in which the lesion is clearly identied. The
 436 SECTION VI: BREAST SURGERY
targeting is then performed on the one remaining
stereo image and the scout image. The software is able
to recognize the 15 separation between the two tar-
geted images and then calculate the appropriate coor-
dinates. It is important to maintain all follow-up prere
and postre images consistent with the targeting
images. On the replaced scout image on the Hologic
Multi-Care Platinum table, with the biopsy device in
position, it is more difcult to visualize the targeted
lesion because of the cartesian targeting platform.
Patient Positioning
Failure to Image a Lesion that is Deep against
the Pectoral Muscle
Consequence
The position of certain lesions, including those against
the chest wall or in the tail of the breast or axilla,
may require innovative positioning by the experienced
technologist.
Grade 1 complication
Repair
One commonly used positioning technique involves
placing the patients arm and part of the shoulder
through the table aperture with the breast. This allows
compression with the paddles of the most posterior
aspect of the breast (Fig. 431).
Figure 431 The patient is positioned with her arm through the
table aperture so the surgeon can gain access to a posterior
lesion.
Obtain Scout and Stereo Digital Images
Acquisition of the rst digital image is the 0, scout image.
Regardless of the approach to the breast (CC, ML, LM,
or caudocranial), this image is taken perpendicular to the
compressed breast. Next, the technologist obtains a set of
stereo images by rotating the tube head to the +15 and
the 15 positions to yield an arc of separation between
the two stereo images of 30.
Not Correctly Positioning the Breast Lesion
within the Compression Window
Consequence
Failure to position the breast so that the lesion to be
biopsied falls within the 5 5 cm opening of the com-
pression paddle such that it appears in the middle third
of the scout image will result in the lesion being
thrown outside the visualization/targeting window
on one of the two stereo images (Fig. 432).
Grade 1 complication
Repair
Repositioning the patient and the breast so that the
breast abnormality falls within the middle third of the
compression paddlebiopsy window should correct
the problem. The technologist will frequently recog-
nize and correct this problem.
Failure to Recognize the Depth of a Lesion
in the Breast
Consequence
A lesion that is too supercial may interfere with the
successful function of certain biopsy devices that
may require the sampling portion of the device to be
within the skin. A vacuum-assisted biopsy (VAB) device
requires maintaining a suction vacuum to pull tissue
toward the sampling portion of the device. If the entire
sampling portion is not beneath the skin because the
lesion is too supercial, the vacuum is unable to main-
tain enough suction to pull the tissue in for biopsy (Fig.
433). The newer large, intact sampling devices utilize
radiofrequency-activated tissue cutting and must, there-
fore, be a certain distance beneath the skin to avoid any
inadvertent burns.
If a lesion is too deep, insertion of the biopsy device
without encroaching on the backside of the breast will be
difcult, and a stroke margin problem will be encoun-
tered. This is especially true for devices that have a spring-
loaded mechanism to advance the biopsy portion of the
device forward into the breast. A stroke margin is the
distance from the device tip after advancing forward to
the back of the breast. There is a problem when this dis-
tance is less than the stroke (forward motion) of the
particular device (negative stroke margin) (Fig. 434).
Grade 1 complication
 43 IMAGE-GUIDED BREAST BIOPSY 437

Correct positioning
Image receptor
Scout Stereo

15 15

Incorrect positioning
Image receptor
Scout Stereo

15 15

Figure 432 Correct positioning with the lesion in the middle third of the biopsy window. Incorrect positioning will cause the lesion
to be taken out of view on one of the stereo images.

Negative Stroke Margin

Stroke (mm)

Post-fire Stroke (0)

margin

Lesion

Figure 433 The back end of the sampling portion of a vacuum- Compression
assisted biopsy device is shown outside the skin during an attempt thickness
to biopsy a supercial lesion. Figure 434 A negative stroke margin occurs when the stroke
margin is less that the forward motion (stroke) of the biopsy
device.

Repair
The use of skin hooks can retract the skin so the back
of the VAB device is covered; thus, there will be ade-
quate suction for biopsy and the skin can be protected
from the heat of the radiofrequency-activated large
intact sample device (Fig. 435). Repositioning the
patient for a different approach to the breast may be all
that is required (e.g., changing from a CC to an ML
or LM approach) to deal with lesions that are deter-
mined to be too deep.
Prevention
The ability to recognize the signicance of lesion move-
ment from one stereo image to the next can alert the
astute physician to the depth (supercial or deep) of
the lesion and further predict a problem of a lesion too
close to the skin or too deep against the back of the
breast or rear image receptor.
 438 SECTION VI: BREAST SURGERY
Figure 435 Skin hooks are one method to adjust for potential
complications related to the biopsy device and a supercial lesion.
Targeting the Lesion
A target is chosen on the abnormality in each of the ste-
reotactic images. The computer software determines the
horizontal, parallax shift of the lesion from stereo image
number one to stereo image number two. The software
then calculates the horizontal, vertical, and depth coordi-
nates. The software can either use the 30 separation
of stereo images or substitute the 15 between the stereo
and the scout images when using the target on scout
technique.
It may be important to consider the biopsy device type
when placing the target on the lesion in each of the stereo
images. If the abnormality in the breast is small, the size
of certain devices when inserted into the breast may hinder
visualization of the lesion. Therefore, placing the targets
inferior to the lesion will allow the lesion to appear supe-
rior to the biopsy device once it is in position and easily
visualized.
A Negative Stroke Margin
Consequence
Once the target information is acquired, whether there
will be an adequate stroke margin becomes evident.
The stroke margin again is the distance from the post-
red position of the biopsy probe to the back of the
breast or rear-image receptor. A negative stroke margin
is encountered when the breast is very thin or the lesion
is in a posterior position in the breast. This situation
may result in the biopsy needle striking the rear-image
receptor and piercing the back of the patients breast
skin (see Fig. 434).
Grade 1 complication
Repair
Several methods are available for eliminating the nega-
tive stroke margin. Taking a different approach to the
breast lesions (e.g., changing from a lateral approach
to a medial approach) may actually provide the neces-
sary amount of tissue behind the lesion. Using a biopsy
device that has a shorter-throw (forward movement of
an automated device) or a biopsy tool that has a shorter
sample notch can reduce the required breast thickness.
Manual insertion of the biopsy instrument (avoiding
the automated ring) allows a controlled forward
motion of the sampling notch into appropriate posi-
tion. Use of the lateral arm allows insertion of the
biopsy device through the side of the compressed
breast, parallel to the compression paddles. Also, use
of the double-paddle technique adds an additional
buffer between the back of the breast and the back
compression paddle.
Prevention
Small or ptotic breasts create one of the most common
difculties in stereotactic breast biopsy. A minimal
compression thickness is required to avoid stroke
margin problems. This minimal compression thickness
varies between biopsy devices. It is important to recog-
nize the patient with these characteristics. Once again,
the ability to accurately access the position of the lesion
and appropriately position the patient for the correct
approach will limit these difculties.
Prepare the Breast: Skin Preparation,
Local Anesthesia, and Skin Incision
The appropriate level of local anesthesia is crucial to limit
patient discomfort and resultant movement. The position
of the biopsy device to the calculated horizontal and ver-
tical coordinates determines the entry site into the breast.
The physician makes a small skin incision with usually a
No. 11 blade scalpel. The incision size may vary from just
a few millimeters to slightly greater than 1 cm, depending
on the biopsy device and whether the incision is oriented
vertically.
Using Local Anesthetic with Epinephrine
in the Skin
Consequence
The skin wheal is raised, usually with 1% lidocaine. For
stereotactic biopsy, it is important to avoid the use of
local anesthesia combined with epinephrine. The con-
stant pressure of the 5 5 cm biopsy window (in the
compression paddle) on the breast for the entire length
of the procedure (sometimes >3045 min) will cause a
decrease in blood ow and result in skin necrosis at
the entrance site. Local anesthesia with epinephrine
(1 : 100,000) is commonly used with the deeper injec-
tion into the breast parenchyma.
Grade 1 complication
Repair
The area of necrosis is usually limited to the size of the
skin wheal. Local wound care is sufcient and rarely
requires surgical excision of the necrotic skin.

Injecting Too Much Local Anesthetic
Consequence
Too much local anesthetic injected into the biopsy site
can also pose potential problems. The injection is not
performed in real time as is done with ultrasound-
guided procedures and, therefore, can cause inadver-
tent lesion movement, and faint, noncalcied lesions
can become difcult if not impossible to see on addi-
tional imaging.
Grade 2 complication
Repair
If the injection is too large, a quantity of local anes-
thetic results in the movement of the lesion such that
adequate sampling may be altered; in this situation, it
will be necessary to remove the biopsy device from the
breast and retarget the lesion. If the lesion is faint
and/or noncalcied, correction is more difcult. Occa-
sionally, waiting a few minutes for reabsorption or dilu-
tion of the local anesthetic is sufcient. Sometimes, a
review of the stereo digital images taken for initial tar-
geting can help judge the correct position of the lesion
by comparing the surrounding breast architecture. A
last resort would be postponing the procedure and
rescheduling.
Prevention
Physicians have employed different techniques for pro-
viding the patient with adequate anesthesia and avoid-
ing the difculties outlined. One technique utilizes a
skin wheal followed by injection of deep local anes-
thetic at the four quarters of the clock (12, 3, 6, 9
oclock positions) positioned at the lateral aspect of the
skin wheal. The 1 inch needle is inserted to the hub
and the local anesthetic is injected gently as the needle
is withdrawn. This technique disperses the local anes-
thetic evenly and provides a region of anesthesia where
tissue sampling will occur. Another technique involves
placing local anesthetic directly at the biopsy site only
after a skin wheal has been raised. A spinal needle can
be directed with stereotactic guidance to the correct
x-, y-, and z-axis (depth) coordinates, and 1 or 2 ml of
local anesthetic is directed in a limited fashion to the
biopsy site. However, the most accurate prevention
starts with recognition of which lesions will be difcult
to visualize when larger amounts of local anesthetic are
injected (faint asymmetrical densities and microcalci-
cations). Prior to injecting larger quantities of local
anesthetic, deploying a metallic clip in the lesion will
eliminate nonvisualization. In addition, allowing injec-
tion of deep local anesthesia only after the biopsy device
is in position and visually aligned with the target lesion
will usually accomplish the goal.
Insertion of the Biopsy Device
The physician inserts the biopsy device into the breast to
the depth determined by the system software.
43 IMAGE-GUIDED BREAST BIOPSY 439
Failure to Recognize Specic Insertion Depths
for Different Devices
Consequence
Certain devices require placement at a depth less than
that calculated by the system software. The pullback
is calculated by the individual manufacturers because of
the device mechanics such as the forward motion or
throw with the amount of dead space at the front of
the needle along with the length of the sampling
portion of the needle. If the required pullback in depth
is ignored for a particular device, the device may be too
deep or not aligned correctly with the lesion and ade-
quate tissue sampling will not occur.
Grade 1 complication
Prevention
It is crucial not only to be familiar with the biopsy
mechanism of the device but also to know the specica-
tions from the manufacturers for stereotactic targeting,
including the pullback depth. The Fischer MammoTest
table allows the specications for all the biopsy devices
physicians will use to be programmed into the system.
The Lorad Multi-Care table requires calibration of each
device to the system on each patient (z-axis = zero),
and the physician manually sets the depth.
Inability to Avoid a Negative Stroke Margin
Consequence
If a negative stroke margin cannot be prevented by
changing the positioning or approach to the breast or
utilizing any of the other previously discussed options,
the negative stroke margin must be recognized and
manipulated to prevent injury to the patient or the
equipment.
Grade 1 complication
Repair
The most commonly employed correction method is
pulling back the prere position of the biopsy needle a
determined number of millimeters until the calculated
stroke margin is adequate. Care must be taken not to
pull back the biopsy device to a distance that places the
sampling notch or biopsy mechanism too far in front
of the lesion such that the lesion will be missed.
Assess Appropriate Alignment between
the Lesion and the Biopsy Device on
Prebiopsy and/or Postbiopsy Alignment
Stereo Digital Images
Failure to Recognize Targeting Errors
Consequence
Interpretation of the stereotactic digital images allows
the physician to determine whether the breast-imaged
abnormality is within the range required by the device
for adequate sampling. Correct targeting demonstrates
 440 SECTION VI: BREAST SURGERY
Vertical error
Probe is above
Probe is below
Figure 436 Y or vertical axis targeting error: The device is visualized above or below the lesion. The directed sampling is illustrated
by the shaded areas on the clock.
symmetrical alignment of the lesion and the biopsy
portion of the device in each stereo image. There are
three types of targeting errors that can occur: x-, y-,
and z-axis targeting errors. X-axis deviation occurs
when the lesion is pushed to the right or the left of the
biopsy needle. Y-axis errors represent movement of the
lesion above or below the needle/probe. Z-axis error
occurs when the sampling notch or biopsy mechanism
is too proximal or too distal to the depth of the breast
abnormality.
Grade 1 complication
Repair
Fortunately, most x- and y-axis targeting errors that
present a problem with stereotactic needle-core biopsy
have a limited effect on the success of a stereotactic
biopsy performed with either a VAB or a large-intake
sample device because these devices can be directed for
specic sampling (Fig. 436). However, if the deviation
from the target is signicant enough to risk a poor
biopsy, the lesion must be retargeted. After the device
is removed from the breast, it is redirected and inserted
with new coordinates.
Prevention
To avoid missing a lesion because of an incorrect depth
(z-axis) coordinate caused by forward motion of the
lesion because of the plowing effect as the biopsy
device is inserted; targets can be placed on the lesion
in each of the new stereo images and the resultant z-
axis depth compared with the original z-axis depth. The
12
9 3
12
9 3
position of the target in each stereo image can also be
helpful in preventing lesion movement and improve the
probability of being able to easily visualize a very small
lesion once the biopsy needle/probe is fully inserted
into the breast. By targeting beneath the lesion, some
of the plowing effect is dispersed, and because the
lesion will be elevated above the device, even a very
small lesion will not be hidden and its position will be
easily assessed.
Adequately Sample the Lesion for Diagnosis
and/or Potential Therapeutic Removal
Failure to Choose the Correct Biopsy Device
Consequence
The tools for specimen acquisition have evolved from
ne-needle aspiration, automated Tru-Cut core needle,
VAB devices to large-intact sampling instruments, and
the technologic advancements have closely paralleled
the acceptance of image-guided breast biopsy.19 Fine-
needle aspiration has long been recognized to have
several potential pitfalls. This includes insufcient
sampling, as high as 38% in some series, with sensitivity
ranges between 68% and 93% and specicity between
88% and 100%.18,19 Cytology rarely provides a specic
benign diagnosis and cannot distinguish between inva-
sive and in situ carcinoma. The automated Tru-Cut
core needle has a lower false-negative rate compared
with that of ne-needle aspiration.57 Standard use of
the 14-gauge needle essentially eliminated the issue of
insufcient sampling.

Several different gauge needles have been evaluated for
Tru-Cut biopsy. The lower rate of insufcient sampling
and increased sensitivity, without increased complications,
has led to a minimum size of 14-gauge as a standard.5,19
The issue of how many cores are needed was addressed
by Dr. Laura Lieberman from Sloan-Kettering in New
York.20 In this study, 145 lesions were biopsied: 92 were
nodular densities, and 53 were microcalcications. Five
cores with a 14-gauge automated Tru-Cut needle yielded
a diagnosis in 99% of biopsies for breast masses. Five cores
yielded a diagnosis in only 87% of the microcalcication
cases, and more than six cores yielded a diagnosis in 92%
of the cases.
The accuracy of needle-core biopsy of microcalcica-
tions came into question. Studies demonstrated upgrad-
ing to carcinoma from 48% to 52% of atypical hyperplasia
identied on stereotactic core biopsy.2123 Not surpris-
ingly, atypical hyperplasia diagnosed at stereotactic core
biopsy has become an indication for open biopsy.
Grade 2 complication
Repair
The VAB device was developed to satisfy the require-
ment of increasing the size of the core sample and the
contiguous nature of the sampling as a proposed solu-
tion to the upgrading issue.24,25 The VAB system was
ideal for performing an image-guided biopsy of calci-
cations under stereotactic guidance. The spring-loaded
mechanism to advance the biopsy probe could elimi-
nate the potential z-axis targeting error by rapidly pen-
etrating the tissue and avoiding the plowing effect of
pushing the lesion forward. But the ability to manually
insert the device without having to utilize the ring
mechanism could help deal with the small breast and
potential stroke margin issues. The vacuum applied to
the sampling portion of the device eliminates the pin-
point accuracy required with automated Tru-Cut biopsy
needles by pulling the lesion toward the sampling
chamber, and the ability of the VAB sampling to be
directional is helpful in dealing successfully with mild
x-axis and y-axis targeting errors.18,24 The improved
accuracy with the directional VAB device lowered the
upgrading of diagnosis compared with that of needle-
core biopsy technology.11,12
Failure to Appropriately Manage
Intraprocedural Bleeding
Consequence
During the course of any image-guided breast biopsy
procedure, bleeding can occur. An excessive amount of
intraprocedural bleeding can potentially interfere with
sampling and, as a result, an accurate biopsy.
Grade 2 complication
Repair
When performing a stereotactic breast biopsy, the most
common biopsy devices used include VAB devices and
43 IMAGE-GUIDED BREAST BIOPSY 441
large intact sample devices. Fortunately, the vacuum
associated with these devices will continue to pull blood
from the biopsy site and allow the inherent biopsy
mechanism the opportunity to continue to obtain tissue
samples. Therefore, from personal experience, the most
important step in dealing with bleeding during a
stereotactic breast biopsy is to continue to take core
samples with appropriate rapidity. The injection of
additional local anesthesia with 1 : 100,000 epinephrine
can be helpful.
Prevention
During the imaging phase of the procedure, it should
be determined whether there are vessels near the lesion
that may be in the pathway of the biopsy device. This
is accomplished by placing a target on the vessel in each
stereo image to check whether the depth is the same
as the lesion. If the lesion and the vessel are at the same
depth, the patient should be repositioned to try to
manipulate the breast so the approach to the lesion
avoids the vessel.
Place a Postprocedure Marker and Obtain
Postprocedure/Clip Placement Stereo Images
Postprocedure digital images are required to document
removal of the microcalcications and, at the same time,
to verify the presence of residual calcications. If the
postprocedure images are taken after clip placement,
it is important to verify accurate and successful clip
deployment.
In addition, accuracy is improved when calcications are
documented within the core samples on a digital specimen
radiograph.26,27 Even in open biopsy surgical literature,
pathologic assessment has identied atypical hyperplasia
and ductal carcinoma in situ (DCIS) at a distance from
the targeted calcications.28
Clip Placement and Migration
Consequence
At the conclusion of a stereotactic breast biopsy, the
placement of a marker has become standard. The
marker has two purposes. The rst and foremost is to
be able to localize a stereotactic biopsy site when all
image evidence of the target lesion has been removed,
and second, to track the site on future mammograms.
The initial clip (Micromark; Ethicon Endosurgery) was
developed as an adjunct to the Mammotome VAB
device to mark the complete removal of calcications
where pathology resulted in the need for follow-up
surgery.29 Clip migration was a reported event.30
The result would be a failure to accurately localize a
biopsy site.
Grade 1 complication
Prevention
The prevention of clip migration involved careful tech-
nique, including pulling the device back to position the
 442 SECTION VI: BREAST SURGERY
ramping up of the clip into the center of the biopsy
cavity, applying active suction to pull the tissue in the
breast toward the clip applier, and rotating and closing
the device away from the clip position (to avoid acci-
dental removal). Postprocedure mammograms could
accurately ensure good clip placement.
The issue of clip migration has also been avoided by the
use of clips or markers that do not require attachment to
the breast tissue. The newer markers include a metallic
component along with an absorbable component such as
Vicryl or collagen that can be visualized by ultrasound.
These newer markers are simply deposited into the biopsy
cavity. As the biopsy site heals, the cavity contracts and
the clip is trapped at the biopsy site.
Obtain a Specimen Radiograph
Postprocedure digital images and specimen radiographs
of calcications and the relationship to diagnostic upgrad-
ing have been addressed earlier. Additional sampling to
remove a greater portion of the targeted lesion can easily
be accomplished if inadequate calcications are visualized
on postprocedure images.
Obtain Adequate Hemostasis and Apply
Appropriate Dressing and/or Wrap
Techniques to avoid hematomas are discussed in the
section on Image-Guided Breast Biopsy with Ultrasound
Guidance, later.
Check Pathology for Concordance with
Radiologic Impression
This topic is addressed in the section on Pathologic
Pitfalls in Image-Guided Breast Biopsy, later.
Image-Guided Breast
Biopsy with Ultrasound
Guidance
OPERATIVE STEPS
Step 1 Evaluate ultrasound
Step 2 Position patient and equipment (ultrasound and
biopsy system)
Step 3 Identify lesion with ultrasound and optimize
image
Step 4 Anesthetize skin and make skin incision after
appropriate antiseptic skin preparation
Step 5 Insert biopsy device
Step 6 Conrmation scan for alignment of lesion with
biopsy device
Step 7 Adequately sample lesion for diagnosis and/or
potential therapeutic removal
Step 8 Place postprocedure marker and obtain
postprocedure/clip placement mammogram
Step 9 Obtain adequate hemostasis and apply appropri-
ate dressing and/or wrap
Step 10 Check pathology for concordance with radio-
logic impression
Step 11 Obtain follow-up imaging
Evaluate the Ultrasound
Failure to Recognize a Possible Cystic Lesion
Consequence
The ultrasound characteristics of a complex cyst fre-
quently mimic those of a solid lesion. If the complex
cystic lesion is not recognized and the physician moves
forward with an image-guided biopsy of a presumed
solid lesion, the physician may waste a more costly
disposable biopsy device instead of a simple syringe or
a needle that would be adequate for a cyst aspiration.
By evaluating the ultrasound images and appreciating
the depth (supercial or deep) of the lesion or its relation-
ship to an implant, the patient can be better positioned
(see the section on Position the Patient and Equipment
[Ultrasound and Biopsy System], later) and the optimal
biopsy device chosen. To be discussed further in the
section on Sample the Lesion for Diagnosis and/or
Potential Therapeutic Removal, later, certain biopsy
instruments are more ideally suited for a very deep or very
supercial lesion.
Grade 1 complication
Prevention
Careful evaluation of the diagnostic ultrasound per-
formed at an outside institution can sometimes elimi-
nate the unnecessary wasting of an expensive disposable
biopsy tool for a lesion that may actually turn out not
to be solid and can be aspirated. Any suggestion of
posterior enhancement or other characteristics of a
possible complex cyst should rst lead to an attempt at
aspiration, even with a larger-gauge needle. Occasion-
ally, duct ectasia may be associated with cystic uid that
requires a needle as large as 14-gauge to aspirate the
contents.
Position the Patient and Equipment
(Ultrasound and Biopsy System)
Poor Positioning of the Patient and Equipment
Consequence/Prevention
Regardless of the imaging modality, the most signi-
cant error in image-guided breast biopsy is of course
missing the lesion or a failure to accurately sample the
breast abnormality and providing the patient a false
sense of security. With ultrasound intervention, the
ability to perform a successful procedure starts with

comfort for the patient and the physician. Positioning
of the physician, the patient, and the ultrasound equip-
ment will greatly facilitate the required alignment of
the biopsy device with the lesion. Standing opposite to
the ultrasound unit will eliminate the physician from
turning his or her head away from the biopsy eld to
see the ultrasound monitor. The optimal setup to
provide the best visualization of the advancing biopsy
device is a straight line between the physicians vision
and the physicians arm down the length of the biopsy
device, along the long axis of the ultrasound trans-
ducer, and up to the ultrasound monitor.
Grade 1 complication
Identify the Lesion with Ultrasound and
Optimize the Image
Inappropriate Gain and Focal Zone Setting
Consequence/Repair
Optimal scanning is achieved by adjusting the time gain
compensation slope to provide a uniform gray scale. An
altered overall gain setting may change the appearance
of the internal echo pattern and limit the ability to
distinguish solid from cystic lesions. To achieve the
optimal lateral resolution, the sonographer must align
the focal zone with the target lesion as illustrated in
Figure 437. This will better demonstrate the retrotu-
moral characteristics such as posterior enhancement.
Grade 1 complication
Poor Optimization of the Lesion Position
for Biopsy
Consequence
If the ultrasound transducer is not positioned so that
the greatest diameter of the lesion is within the ultra-
sound plane, the needle-core biopsy device may miss
the lesion by veering off the edge of a solid mass. If
the lesion is not positioned correctly on the ultrasound
Figure 437 Alternating the focal zone, as seen with this breast phantom, will alter the lateral resolution. The ideal lateral resolution
occurs when the focal zone is aligned with the target.
43 IMAGE-GUIDED BREAST BIOPSY 443
monitor, the shortest skin-to-lesion distance will not be
achieved.
Grade 2 complication
Prevention
Two scanning techniques are crucial for identifying the
area of greatest lesion diameter and positioning the
lesion on the ultrasound monitor to limit the skin-to-
lesion distance. Movement of the transducer perpen-
dicular to the long axis of the transducer allows the
scanner to visualize the lesion from end to end and nd
the widest portion of the lesion. Sliding the transducer
in the direction parallel with the long axis will change
the position of the lesion on the ultrasound monitor.
Prepare the Breast: Skin Preparation,
Local Anesthesia, and Skin Incision
Failure to Judiciously Administer
Local Anesthetic
Consequence
Too much local anesthetic injected into the breast
parenchyma carries the risk of the inability to visualize
a smaller target lesion. In addition, the injection of too
much local anesthetic in one area can create a false
lesion that mimics a cyst. This can be especially frustrat-
ing when the target lesion is cystic.
Grade 2 complication
Repair
If the visibility of the target lesion has been hindered
by the local anesthetic administration, few alternatives
are available to continue the biopsy. A very skilled
sonographer could use an aspiration needle to aspirate
any collections of local anesthetic that are interfering
with the biopsy. However, the usual course of action
would be to wait until the local anesthetic has been
reabsorbed. Attempting to perform the biopsy without
optimal visualization of the lesion could result only in
 444 SECTION VI: BREAST SURGERY
an inadequate sampling of the lesion and a diagnosis
that may falsely reassure the patient.
Prevention
After a sterile or clean preparation of the skin and
the ultrasound transducer, local anesthetic (usually 1%
lidocaine) is injected at the proximal end of the ultra-
sound transducer. Once a skin wheal is made, intrapa-
renchymal injection of local anesthetic is performed
under direct ultrasound visualization. By monitoring
the injection with ultrasound, adequate anesthesia is
obtained without compromising visibility. The tech-
nique of injection under direct visualization is discussed
further with prevention of inadvertent biopsy of the
skin and prevention of pneumothorax below.
Insert the Biopsy Device
Failure to Visualize the Advancing Biopsy
Device Tip
Consequence
Pneumothorax, hemothorax, and biopsy of pectoral
muscle (with associated increased bleeding and pain)
are among the potential problems associated with the
inability to conrm the position of the advancing biopsy
device.
Grade 2 complication
Repair
The details of treatment of a rare pneumothorax or
hemothorax, and the placement and management of
chest tubes are not discussed in this section. Manage-
ment of Bleeding and Hematoma are discussed
later.
Prevention
To avoid potential advancement of the device into the
pectoral muscle or lung, multiple issues are addressed.
The key to visualizing the advancing tip of any device
resides in both maintaining alignment of the device
with the ultrasound scan plane and keeping the advanc-
ing device as parallel with the face of the ultrasound
transducer as possible. To achieve parallel positioning
with the transducer, regardless of the lesion depth, will
require that the patient be positioned in lateral decu-
bitus with a pillow behind the shoulder. In addition,
the ultrasound transducer can be gently tilted into the
breast away from the advancing device. Local anesthe-
sia can also be injected under direct ultrasound visual-
ization; by directing the needle beneath the lesion, it
can be raised off or away from the pectoral muscle.
Another way to avoid inadvertent pneumothorax is to
use a nonring device. The VAB as well as the large
intact sample devices are positioned below a lesion
without a spring-loaded ring mechanism and the
acquisition of tissue is directed superiorly.
Conrmation Scans for Alignment of the Lesion
with the Biopsy Device
Failure to Align the Lesion with
the Biopsy Device
Consequence
Failure to conrm with ultrasound imaging that the
biopsy device tip or its sampling area is aligned correctly
with the lesion will of course lead to inadequate biopsy
of the lesion and potentially falsely reassuring a patient
of a benign diagnosis.
Grade 2 complication
Prevention
To avoid missing signicant portions of the lesion with
ultrasound-guided needle core biopsy, by the forward
movement of the inner and outer cannula, the needle
tip is brought just to the front edge of the lesion and
does not penetrate into the lesion prior to ring. When
performing a needle-core biopsy, in which it is crucial
to know whether the needle has penetrated the lesion,
a conrmation scan is needed to avoid a false image
created by the overlap of the narrow ultrasound scan
plane with the needle just at the edge of the lesion
(image averaging). The physician may view the ultra-
sound image and interpret it as a successful biopsy
although the needle has not actually penetrated the
lesion (Fig. 438). By moving the ultrasound trans-
ducer perpendicular to its long axis, the lesion can be
visualized from one end through its middle to the other
end of the lesion. It is necessary to see a portion of the
lesion without the needle, followed by the needle with
the lesion, and then continuing the scan in the same
direction to again visualize the lesion without the needle.
This will conrm that the needle is in the lesion.
The success of ultrasound-guided VAB or large intact
biopsy is enhanced by careful attention to the technical
aspect of the procedure. Patient positioning (lateral decu-
bitus), injection of local anesthetic posterior to the lesion
for a lifting effect, and torquing down of the biopsy device
handle as the probe approaches the underside of the lesion
all serve to provide a shallow angle of insertion and easier
access underneath the lesion, especially when the lesion is
deep within the breast parenchyma.
When the biopsy device is in position for a biopsy,
ensuring an adequate sampling requires a conrmation
scan to assess the relationship of the device and the lesion.
VAB devices and one of the large intact sample devices
(Rubicor Medical, Halo, Redwood City, CA) are posi-
tioned below the lesion. If these are not positioned
beneath the breast target lesion, the artifact created by the
device would eliminate visualization of any portion of the
lesion below the biopsy probe. To conrm that the device
is centered beneath the lesion, the ultrasound transducer
is rotated 90. The device is then visualized in cross-
section, and it becomes obvious whether it is centered
underneath the lesion, also seen in cross-section.
 43 IMAGE-GUIDED BREAST BIOPSY 445

Figure 438 When the biopsy needle and the edge

of a lesion are both within the ultrasound scan plane,
image averaging occurs and creates the perception
that the needle is in the lesion.

Sample the Lesion for Diagnosis and/or

Potential Therapeutic Removal
Failure to Choose the Appropriate Biopsy
Device for Ideal Sampling
Consequence
Cytologic or histologic conrmation of malignancy is
the minimum requirement for ultrasound-guided
biopsy of indeterminate or suspicious solid lesions.
Fine-needle aspiration biopsy is a quick, inexpensive
technique to delineate benign from malignant solid
breast masses. However, the same issues surrounding
the use of ne-needle aspiration in stereotactic image-
guided breast biopsy apply to ultrasound-guided
procedures.
Grade 2 complication
Figure 439 A postprocedure hematoma after a vacuum-assisted
Prevention biopsy. No surgical intervention was required.
Ultrasound ne-needle aspiration is ideally suited to
evaluate lesions in areas such as the axilla where more
invasive biopsy devices may be difcult or dangerous. remove image evidence and especially palpability of prob-
The diagnosis of lymph node metastasis by ne-needle ably benign solid masses.31
aspiration can assist with preoperative staging in con-
sideration of neoadjuvant chemotherapy or eliminating Place a Postprocedure Marker and Obtain
sentinel lymph node biopsy by conrming positive Postprocedure/Clip Placement Mammogram
cytology in clinically suspicious lymph nodes.
Clip placement and potential pitfalls have been addressed
The use of automated Tru-Cut needle-core biopsy
previously.
eliminates the same problems with ne-needle aspiration
that are seen with stereotactic breast biopsy such as insuf-
cient sampling and the inability to provide the histologic Obtain Adequate Hemostasis and Apply
type and grade of a diagnosed cancer. Appropriate Dressing and/or Wrap
VAB and large intact sample technology are also avail-
Bleeding and Hematoma
able with ultrasound guidance. The indications for an
ultrasound-guided VAB are similar to those for needle- Consequence
core biopsy, including any indeterminate, ultrasound- The incidence of hematoma with image-guided breast
visible, palpable or nonpalpable solid masses. If the biopsy is reported to be 2% to 8% (Fig. 439). It is
physician is interested in the potential therapy of probably extremely rare for bleeding or hematoma to result
benign breast abnormalities, VAB devices or large intact in any postimage-guided surgical procedures. This
sampling devices would be required. Both of these device authors experience is that no patient has required
categories have successfully demonstrated their ability to operative intervention. Bruising and small hematoma
 446 SECTION VI: BREAST SURGERY
formation are common, especially near the biopsy
insertion site. The size of the hematoma will, of course,
contribute to the level of pain and discomfort.
Grade 1 complication
Prevention/Repair
Manual compression is the mainstay for achieving
hemostasis in image-guided breast biopsy and prevent-
ing hematomas. It is important for the pressure to be
applied across the biopsy track created by the device.
When a VAB or large intact sample device has been
used to remove the image evidence of the lesion, a
larger biopsy cavity is created and there is a greater risk
of bleeding/hematoma. It is important that the manual
pressure and the pressure dressing, in particular, be
applied to the site of the lesion and not only at the
incision. Prevention of a hematoma can also be inu-
enced by placing the patient in a chest wrap. Conserva-
tive management with ice and pressure wraps is
sufcient.
Check Pathology for Concordance
with Radiologic Impression
This topic is addressed in the section on Pathologic
Pitfalls in Image-Guided Breast Biopsy.
PATHOLOGIC PITFALLS IN
IMAGE-GUIDED BREAST BIOPSY
Not Performing a Further Procedure with
a Diagnosis of Benign Papillary Lesion on
Core Biopsy
Consequence
The pathologist is confronted with the following deci-
sion points when presented with a papillary lesion:
1. Distinguishing benign, atypical, and malignant papil-
lary lesions with limited material.
2. Establishing a diagnosis with the realization that the
sample may not contain the most worrisome histology
present in the lesion.
3. Distinguishing invasive carcinoma from a fragmented
and distorted sclerosing papillary lesion.
Papillary lesions of the breast can be divided into benign
and malignant categories. Benign lesions include solitary
intraductal papilloma, multiple papillomas, and atypical
hyperplasia within a papilloma. If a diagnosis of atypia
is mentioned, further surgical excision needs to be per-
formed. What is less clear is whether or not complete
surgical excision is required for a diagnosis of benign
intraductal papilloma. Solitary intraductal papilloma
usually presents as a well-dened mass, whereas multiple
intraductal papillomas typically present as a nodular mass
or with microcalcications.32 In both instances, a cystic
component may be identied on ultrasound examination.
The signicance of either diagnosis is an increased risk of
developing breast cancer. Based on a review of 372 soli-
tary papillomas and 41 multiple papillomas published
from the Mayo clinic, there is an approximately twofold
increased risk in the case of solitary papilloma and a three-
fold increase in the case of multiple papillomas.33 Atypia,
when present, is more often associated with multiple pap-
illomas than with solitary central papillomas.34 The atypia
in papillary lesions is frequently unevenly distributed and
is usually present in less than 50% of the papilloma.35 The
relative risk of developing carcinoma when atypia is present
versus when atypia is not identied is a 7.5-fold increase.36
In addition, that risk is in the ipsilateral breast as opposed
to a more generalized risk associated with atypical intra-
ductal hyperplasia (AIDH).
Studies have demonstrated the presence of atypia and/
or malignancy in 0% to 44% of excision specimens when
a diagnosis of benign papillary lesion is rendered on a core
biopsy.3746 In general, a relationship exists between the
presence of atypia and/or malignancy in excisional speci-
mens and the amount of residual lesion remaining after
core biopsy. This is not surprising given the focal nature
of atypia, when present. Because of the possibility of
missing the most worrisome histology and the fact that
papilloma with atypia is a precursor lesion, most experts
recommend complete radiographic excision of the imaging
abnormality if a diagnosis of benign papillary lesion is
rendered by the pathologist.
When sclerosing papillary lesions are removed in small
fragments, they can be difcult to distinguish from radial
sclerosing lesions and invasive carcinomas. The sclerosis
can entrap benign epithelial elements, simulating an inva-
sive carcinoma. The use of immunostains can effectively
demonstrate the presence or absence of a myoepithelial
cell layer to aid in the differential diagnosis of an invasive
cancer but cannot help to distinguish a radial sclerosing
lesion.
It should be noted, however, that most malignant pap-
illary lesions behave in a relatively indolent manner.47
Whereas they occasionally metastasize to lymph nodes,
distant metastasis is rare.
Prevention
Complete removal of the imaging abnormality should
be performed.41,42,45,46,48 The biopsy device chosen by
the surgeon may dictate further procedures. For
example, if a lesion, highly suspicious for a papilloma,
is sampled with a 14-gauge spring-loaded biopsy device,
a second procedure will need to be performed even if
a diagnosis of a benign papillary lesion is rendered.
Limited sampling of a papillary lesion may miss atypia,
which is usually present only focally, and atypia is
believed to be a precursor lesion. Therefore, when
the probability of a papillary lesion, such as a well-
dened subareolar mass, is high, a large-core biopsy
device or whole intact excisional biopsy device should
be used.

Figure 4310 Low-power hematoxylin and eosin (H&E) micro-
scopic image of a completely resected intraductal papilloma. The
biopsy was obtained using a whole intact biopsy device, preserving
the architecture and eliminating the need for further surgery.
A second factor in selecting a biopsy device is preserva-
tion of tissue architecture. Biopsy devices can be thought
of as providing puzzle pieces to the pathologist. The larger
the pieces, the less the architecture is distorted and the
easier it is for a pathologist to establish a diagnosis. In
addition to deciding how much tissue should be sampled,
the radiologist or surgeon must also decide whether to
remove the lesion in one piece (whole intact), to optimally
preserve the architecture, or in pieces. If the lesion is to
be sampled in pieces, the size of the pieces must be deter-
mined. Because architecture is critical in differentiating a
sclerosing papillary lesion from other lesions, larger pieces
allow the pathologist to obtain a better overall assessment
of the architecture.
Removing all imaging evidence of a potential papillary
lesion will greatly reduce the need for further surgery
if a diagnosis of benign papillary lesion is rendered
(Fig. 4310).
Obtaining a HER-2 Result on a Core
Biopsy Specimen
Consequence
HER-2 is an oncogenic protein that may be overex-
pressed in up to 20% of high- and intermediate-grade
invasive breast carcinomas. It is rarely overexpressed in
low-grade ductal or classic invasive lobular carcino-
mas.49 Patients with HER-2 overexpression benet
from targeted antiHER-2 therapies, such as trastu-
zumab, in both the adjuvant and the metastatic set-
tings.5052 The assessment of HER-2 overexpression is
most commonly performed by immunohistochemistry,
and patients whose tumor cells show 3+ overexpression
have the greatest likelihood of response to antiHER-2
therapy.
43 IMAGE-GUIDED BREAST BIOPSY 447
The ability of a pathologist to accurately assess a HER-
2 immunostain can be compromised by four major arti-
facts: tissue crush, tissue retraction, thermal injury, and
edge artifact. These artifacts can cause the HER-2 anti-
body to diffuse unevenly, causing the tumor cells in the
area of artifact to see a higher concentration of antibody
than expected. Tissue crush is caused when a thin needle
is forced into tissue and the cells along the edge are
crushed. The cytoplasm becomes streamed and distorted.
Tissue retraction is dened as the separation of breast
epithelial cells, benign or malignant, from stromal ele-
ments, creating a cleftlike space. The use of VAB devices
can accentuate this artifact, but it may also occur as part
of routine tissue processing. Thermal injury is caused by
the use of cautery. It causes the cells to take on a wind-
swept appearance and increases nuclear chromasia. Edge
artifact is seen in all tissues and is caused by antibody
pooling along the edge of a specimen, affecting tissue
located within 1 mm of the edge. Thus, a core biopsy
measuring 2 mm in diameter is mostly edge artifact, with
the exception of the exact middle of the core. Core biop-
sies with a small diameter, such as a 14-gauge spring-
loaded core, are virtually all edge artifact.
Fluorescence in situ hybridization (FISH) is a method
that allows detection of the HER-2 gene.53 The technique
involves exposing the tumor nuclei via digestion of the
cell membrane and cytoplasm, heating the DNA until it
uncoils, ooding the sample with a uorescently tagged
complementary sequence to the HER-2 gene, and then
cooling the DNA allowing it to recoil with the HER-2
gene now uorescently tagged. The number of HER-2
genes in each tumor nucleus can then be enumerated.
Because two HER-2 genes are present in all normal cells,
one from mom and one from dad, it is essential that only
tumor nuclei be assessed. The key to counting only the
tumor nuclei is preservation of tissue architecture.
It has been noted that approximately 18% of breast
tumors scored as 3+ by HER-2 immunohistochemistry
and 12% of breast tumors assessed as having gene ampli-
cation do not show overexpression or gene amplication
when repeated in a central reference laboratory.54,55 This
high rate of error has resulted in the American Society of
Clinical Oncology (ASCO) and the College of American
Pathologists (CAP) issuing joint guidelines in an effort to
improve HER-2 assessment in breast cancer.56
Prevention
The artifacts caused by core biopsy all lead to potential
overstaining by immunohistochemistry. Thus, tumors
assessed as 3+ may be truly 3+ or may be falsely positive
as a result of an artifact. If the diameter of the biopsy
core is less than 2 mm, cores assessed as 3+ should be
conrmed with FISH testing or be repeated on the
lumpectomy specimen, because the majority of the core
is edge artifact. Even if large-core biopsy devices are
used, care must be taken to avoid scoring artifacts
because these will still be present in the biopsy.
 448 SECTION VI: BREAST SURGERY
Figure 4311 Low-power HER-2 immunostained slide shows
apparent strong expression of the protein. However, the staining
cannot be clearly visualized on the membrane and is the result of
both edge and crush artifact typical of a core biopsy specimen.
Before relying on the results of a FISH test, you must
be assured that the correct cells were examined. Because
only tumors can show amplication of the HER-2 gene,
if gene amplication is detected, tumor cells must have
been examined. The only possibility for error is if in situ
and invasive carcinoma are both present and only the in
situ carcinoma shows amplication of the HER-2 gene.
Although this does occur, it is unusual. More problematic
is when FISH testing does not show amplication of the
HER-2 gene. In this circumstance, one must always ques-
tion whether tumor cells were observed. It can be difcult
to distinguish tumor cells from normal cells on uores-
cence microscopy, especially when the tumor is limited
and intermixed with benign pathology such as adenosis.
The pathologist relies on architecture and comparison
with an adjacent hematoxylin and eosin (H&E)stained
section to select the tumor cells. As a general rule, if the
pathologist is struggling to establish the diagnosis on the
H&E slide, it will be difcult to identify the tumor cells
by uorescence. The larger the core biopsy, the better the
preservation of tissue architecture, and the more reliable
the FISH result (Fig. 4311).
Not Obtaining an Estrogen Receptor
Immunostain on a Core Biopsy Specimen
Consequence
The determination of estrogen receptor (ER) should
be performed on all breast carcinomas. The accurate
determination of ER status is largely dependent on the
amount of tumor assessed, tissue xation, and the assay
used. Currently, ER status is usually assessed by immu-
nohistochemistry. Unlike HER-2, which is a mem-
brane protein, ER is a nuclear stain and is not affected
by the artifacts such as edge artifact, tissue crush, tissue
retraction, or cautery artifact.
Studies have shown that ER status is an excellent pre-
dictor of response to antiestrogen therapy.57,58 The initial
studies were performed by ligand-binding assay. This assay
requires a large amount of fresh tissue, which is ground
up and assessed quantitatively. Assessment of ER on for-
malin-xed parafn-embedded tissue was found to be
even more predictive of response to antiestrogen therapy
when using a specic immunohistochemical assay with a
specic scoring system.58 This is not surprising because the
tissue included in the ligand-binding assay usually included
a mixture of tumor cells, stroma, and often, benign breast
epithelial cells. Unfortunately, in current practice, many
different immunohistochemical assays and scoring systems
are used to assess ER status, leading to signicant errors
in ER testing results.
These errors can be broken down into several problems
including tissue xation, tissue processing, antigen retrieval
methods, antibody clones, amount of tissue assessed,
scoring system, and cutoff levels. With respect to core
biopsies, tissue xation and the amount of tissue examined
are of most concern. ER determination is greatly affected
by tissue xation. Underxation of breast tissue can cause
a marked decrease in the ability of immunohistochemistry
to detect ER.59 Because core biopsies tend to be signi-
cantly smaller than excisional specimens, they x more
rapidly, which is optimal for ER assessment. It is not
unusual to see weak expression of ER on a core biopsy
while no expression is noted on the excision specimen.
Prevention
ER determination should be performed on all core
biopsies because of more optimal tissue xation.60 If no
expression of ER is noted, ER status should be reas-
sessed on the excisional specimen. Expression in as
little as 1% of the invasive tumor cells is associated
with signicantly greater responsiveness to antiestrogen
therapy than those tumors showing no expression.
Because the amount of tissue examined in a core biopsy
is typically less than the amount examined in an exci-
sional specimen, lack of expression in a core biopsy may
be the result of incomplete sampling.
Not Performing a Further Procedure with
a Diagnosis of AIDH on Core Biopsy
Consequence
The diagnosis and signicance of AIDH are dened
based on the follow-up of patients who underwent
excisional biopsy. When AIDH is found on a core
biopsy, the question is whether it is representative of
the entire lesion or whether it is indicative of a more
worrisome pathology. On a molecular level, AIDH
and low-grade intraductal carcinoma are undistinguish-
able.6163 The two lesions are sometimes difcult for the
pathologist to separate, even on excisional specimens,
let alone on core biopsy samples in which more limited
tissue is available. Even when a denitive diagnosis of

AIDH can be rendered on core biopsy, it is frequently
associated with low-grade DCIS.
When diagnosed on core biopsy, AIDH is frequently
upgraded to DCIS or invasive carcinoma once the lesion
is excised.21,6468 In general, the more tissue removed at
core biopsy, the smaller the percentage of cases that will
be diagnosed as carcinoma on excision. Approximately
40% of core biopsies diagnosed as AIDH using a 14-gauge
biopsy device will show carcinoma on excision whereas
only about 20% will show carcinoma when AIDH is diag-
nosed with an 11-gauge VAB device.69 Recently, it has
been suggested that it may be important to note the
number of foci of AIDH on core biopsy and that the
number of foci may be predictive of the presence of car-
cinoma on the excisional biopsy.70 When AIDH was
limited to only one or two foci, carcinoma was not seen
on the subsequent excisional biopsy specimen; the inci-
dence of carcinoma was 50% when three foci of AIDH
were identied and 87% when four or more foci were
identied.
I believe this approach is too simplistic and that
attention should be paid to the type and extent of the
mammographic lesion. If the lesion presents as microcal-
cications, carcinoma is more often detected if the mam-
mographic lesion is not completely removed. However,
even if the mammographic microcalcications are com-
pletely removed, carcinoma may still be found at excision.
If the mammographic lesion presents as a mass, there is
only a 5% incidence of carcinoma at excision.71 It has been
noted that when a micropapillary pattern is identied,
most excisional specimens will contain a micropaillary
DCIS.70
Prevention
Whereas there continues to be much interest in den-
ing a subset of AIDH patients who do not require
subsequent excision, no such category can be dened
reliably. AIDH has similar molecular alterations to
those seen in low-grade DCIS and should be treated.
It is frequently found at the periphery of DCIS, and
thus, a concurrent carcinoma can be truly excluded
only if the surrounding tissue is examined and no car-
cinoma is seen.66 AIDH is a signicant risk factor for
the development of invasive breast cancer, conferring a
relative risk of four to ve times and is about equal in
both breasts.72,73
Not Performing a Further Procedure with a
Diagnosis of Angiolymphoid Hyperplasia/Lobular
Carcinoma In Situ on Core Biopsy
Consequence
When angiolymphoid hyperplasia (ALH) or lobular
carcinoma in situ (LCIS) is found on excisional biopsy,
no further surgery is performed because the lesions are
believed to be markers of a generalized increased risk
of developing invasive breast carcinoma that occurs
43 IMAGE-GUIDED BREAST BIOPSY 449
with equal frequency in both breasts.7480 LCIS/ALH
is not typically associated with a mammographic or
ultrasound abnormality and, thus, is usually an inciden-
tal nding rather than the pathology that led to the
core biopsy. It has an incidence of less than 2% in most
core biopsy studies.42,79,8184 Because of its low inci-
dence, our knowledge of ALH/LCIS on core biopsy
is mostly derived from retrospective trials. Pooling
these studies, approximately 19% of excisional biopsies
after a diagnosis of ALH/LCIS show carcinoma.85
Approximately 55% of these show invasive carcinoma
(30% invasive lobular), and 45% show intraductal
carcinoma.
Liberman and coworkers84 put forth criteria strongly
recommending surgical excision if there is radiologic-
pathologic discordance, if another lesion requiring exci-
sional biopsy (such as atypical ductal hyperplasia [ADH])
is also present, or if the histologic features of the ALH/
LCIS cannot be easily distinguished from DCIS.84
Prevention
Because ALH/LCIS is not associated with a radio-
graphic abnormality, there is likely to be radiologic-
pathologic discordance. Although concern has been
raised that these studies might be biased because not
all patients who were diagnosed with ALH/LCIS on
core biopsy underwent excisional biopsy, until further
studies are available, excisional biopsy seems prudent.
Not Performing a Further Procedure with a
Diagnosis of Flat Epithelial Atypia (Atypical
Columnar Cell Alteration) on Core Biopsy
Consequence
Columnar cell lesions are the most common cause of
pleomorphic microcalcications seen on core biopsy.
These lesions have been described under a number of
different names ranging from blunt duct adenosis on
the benign side to clinging carcinoma on the malig-
nant side. The signicance of columnar cell lesions is
the company they keep. Atypical columnar cell lesions
(at epithelial atypia) have been associated with low-
grade in situ and invasive ductal and/or lobular carci-
nomas.86 In one review, 95% of cases of pure tubular
carcinoma were associated with atypical columnar cell
lesions.87 On a molecular level, columnar cell lesions
frequently show loss on chromosome 16 similar to
those seen in low-grade carcinomas.88 For years, these
lesions were largely ignored when identied in exci-
sional biopsy specimens and the association with low-
grade carcinomas was not appreciated. Retrospective
studies looking at benign breast biopsies containing
overlooked atypical columnar cell lesions did not show
a subsequent invasive carcinoma. When columnar cell
alterations were present without an associated carci-
noma, the lesions did not appear to confer an increased
risk of malignancy.
 450 SECTION VI: BREAST SURGERY
Figure 4312 H&E-stained microscopic slide shows at epithelial
atypia. The nuclei in the lining cells are more vesicular with visible
nucleoli. They have lost their polarity and have a much more
uniform and focally rounded appearance.
Prevention
Columnar cell alterations are commonly seen because
of their frequent association with pleomorphic micro-
calcications. If a dedicated breast pathologist is not
available at your institution, it is worth asking your
pathologists if they are aware of this entity and the
current histologic criteria. It is essential that the pathol-
ogist be familiar with the terminology and criteria. If
atypia is present, complete surgical excision of the
lesion is advised because of the possible association with
an in situ or invasive carcinoma. If no associations are
found, the probability of developing into an invasive
carcinoma is exceedingly low (Fig. 4312).
Pathology Does not Correlate with Imaging
Findings?/No Calcications Found on Pathology
When Calcications Were Identied on Your
Imaging Study (Tissue Processing in General)
Consequence
Although they are not encountered very often, the
inability to demonstrate microcalcications on histo-
logic examination can be problematic. If calcications
cannot be demonstrated, and the lack of microcalcica-
tions cannot be explained, complete excision of the
lesion should be performed, assuming microcalcica-
tions are still remaining in the breast.
When performing an image-guided biopsy for micro-
calcications, large-core or whole intact biopsy devices
should be utilized. Studies have shown that larger biopsy
samples and more cores will remove more of the calci-
cations and require few excisional biopsies owing to
radiographic-pathologic discrepancies.8991
Prevention
This is denitely the case in which an ounce of preven-
tion is worth a pound of cure. The radiologist/surgeon
should radiograph all of the removed cores as well as
obtain a postbiopsy lm to ensure that the calcications
have been removed and a specimen radiogram to ensure
that they are present in the core biopsy specimens.
Once documented, the cores containing the microcal-
cications should be submitted separately from
the cores that do not show radiographic evidence of
calcications. This will allow the pathologist to concen-
trate on the more suspicious cores and potentially
examine more levels on sections thought to contain
calcications.
If microcalcications are not identied by the patholo-
gist, several steps should be taken. The rst step is for the
pathologist to polarize the H&E slides. Calcications
composed of calcium oxylate are not easily demonstrated
on the H&E stain but are easily demonstrated on polariza-
tion.92,93 This type of calcication is most commonly seen
associated with apocrine metaplasia. Assuming that calci-
cations are still not identied, the next step should be to
x-ray the tissue block. If no calcications are identied
within the block, but preprocessing radiographs demon-
strated the microcalcications, it can be assumed that the
calcications dissolved in processing. This happens very
rarely. If calcications are still demonstrated in the paraf-
n-embedded block, deeper sections should be obtained.
The sections should be cut on a fresh microtome blade,
if possible. Occasionally, microcalcications cannot be cut
by a microtome blade and the calcications are launched
as small projectiles rather than being cut. These can be
detected as holes in the tissue that represent remnants of
where the microcalcications used to reside.
Lack of Radiographic and Pathologic
Correlation, Whatever the Cause, Requires
Complete Surgical Excision
Not Performing a Further Procedure with
a Diagnosis of Radial Scar on Core Biopsy
Consequence
Most radial scars are incidental ndings measuring
approximately 4 mm in size. Based on data from the
Nurses Health Study, women with radial scars dem-
onstrate a twofold increase in risk of invasive breast
cancer; this risk increases with the size of the radial
scar.94 The risk is believed to be bilateral, but larger
radial scars may be associated with DCIS and invasive
carcinomas. Carcinomas arising in association with
radial scars are frequently located at the periphery of
the lesion, causing them to be missed if the center of
the lesion is targeted.
It is important to note whether a radial scar is an inci-
dental nding or whether it is the targeted lesion. There
is a signicantly higher association of carcinoma and
AIDH in lesions identied mammographically than those
lesions found incidentally. There does not appear to be
any distinguishing mammographic feature that allows

Figure 4313 Triple immunostaining for P63, cytokeratin 5/6,
and cytokeratin 18 in the same radial sclerosing lesion as seen on
the H&E stain. P63 and cytokeratin 5/6 highlight cells with myo-
epithelial/basal differentiation. Both antibodies are visualized with
diaminobenzidine (DAB) (brown). P63 is a nuclear, and cytokeratin
5/6 is a cytoplasmic. Cytokeratin 18, a cytoplasmic stain, is visualized
with fast red. The presence of two cell types conrms the prolif-
eration as benign.
radiographic separation of radial scars harboring carcino-
mas from those that do not harbor such foci.95
Prevention
All mammographically detected radial scars and all
radial scars measuring 6 mm or larger should undergo
excision. Sloane and Meyers96 reported a 30% incidence
of carcinoma when the radial scar measures 6 mm or
larger and an incidence of only 2.6% with smaller radial
scars. Given the small number of radial scar studies and
the low incidence of radial scars in general, it seems
prudent to recommend excision for all mammographi-
cally detected radial scars and certainly all radial scars
measuring larger than 6 mm (Fig. 4313).
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of benign breast disease and the risk for breast cancer. The
43 IMAGE-GUIDED BREAST BIOPSY 453
Cancer and Steroid Hormone Study Group. Cancer
1992;69:14081414.
74. Andersen JA. Lobular carcinoma in situ of the breast. An
approach to rational treatment. Cancer 1977;39:2597
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75. Bodian CA, Perzin KH, Lattes R. Lobular neoplasia.
Long-term risk of breast cancer and relation to other
factors. Cancer 1996;78:10241034.
76. Ottesen GL, Graversen HP, Blichert-Toft M, et al.
Lobular carcinoma in situ of the female breast. Short-term
results of a prospective nationwide study. The Danish
Breast Cancer Cooperative Group. Am J Surg Pathol
1993;17:1421.
77. Page DL, Kidd TE Jr, Dupont WD, et al. Lobular
neoplasia of the breast: higher risk for subsequent invasive
cancer predicted by more extensive disease. Hum Pathol
1991;22:12321239.
78. Rosen PP, Kosloff C, Lieberman PH, et al. Lobular
carcinoma in situ of the breast. Detailed analysis of 99
patients with average follow-up of 24 years. Am J Surg
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79. Shin SJ, Rosen PP. Excisional biopsy should be performed
if lobular carcinoma in situ is seen on needle core biopsy.
Arch Pathol Lab Med 2002;126:697701.
80. Wheeler JE, Enterline HT, Roseman JM, et al. Lobular
carcinoma in situ of the breast. Long-term followup.
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81. Berg WA, Mrose HE, Ioffe OB. Atypical lobular hyperpla-
sia or lobular carcinoma in situ at core-needle breast
biopsy. Radiology 2001;218:503509.
82. Burak WE Jr, Owens KE, Tighe MB, et al. Vacuum-
assisted stereotactic breast biopsy: histologic underestima-
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703.
83. Elsheikh TM, Silverman JF. Follow-up surgical excision is
indicated when breast core needle biopsies show atypical
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tive study of 33 patients with review of the literature. Am
J Surg Pathol 2005;29:534543.
84. Liberman L, Sama M, Susnik B, et al. Lobular carcinoma
in situ at percutaneous breast biopsy: surgical biopsy
ndings. AJR Am J Roentgenol 1999;173:291299.
85. Jacobs TW, Connolly JL, Schnitt SJ. Nonmalignant
lesions in breast core needle biopsies: to excise or not to
excise? Am J Surg Pathol 2002;26:10951110.
86. Rosen PP. Columnar cell hyperplasia is associated with
lobular carcinoma in situ and tubular carcinoma. Am J
Surg Pathol 1999;23:1561.
87. Abdel-Fatah TM, Powe DG, Hodi Z, et al. High fre-
quency of coexistence of columnar cell lesions, lobular
neoplasia, and low grade ductal carcinoma in situ with
invasive tubular carcinoma and invasive lobular carcinoma.
Am J Surg Pathol 2007;31:417426.
88. Simpson PT, Gale T, Reis-Filho JS, et al. Columnar cell
lesions of the breast: the missing link in breast cancer
progression? A morphological and molecular analysis. Am
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89. Dahlstrom JE, Sutton S, Jain S. Histologic-radiologic
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22:256259.
 454 SECTION VI: BREAST SURGERY
90. Meyer JE, Smith DN, DiPiro PJ, et al. Stereotactic breast
biopsy of clustered microcalcications with a directional,
vacuum-assisted device. Radiology 1997;204:575576.
91. Reynolds HE, Poon CM, Goulet RJ, et al. Biopsy of
breast microcalcications using an 11-gauge directional
vacuum-assisted device. AJR Am J Roentgenol 1998;
171:611613.
92. Tornos C, Tornas C, Silva E, et al. Calcium oxalate
crystals in breast biopsies. The missing microcalcications.
Am J Surg Pathol 1990;14:961968.
93. Truong LD, Cartwright J Jr, Alpert L. Calcium oxalate in
breast lesions biopsied for calcication detected in
screening mammography: incidence and clinical signi-
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94. Jacobs TW, Byrne C, Colditz G, et al. Radial scars in
benign breast-biopsy specimens and the risk of breast
cancer. N Engl J Med 1999;340:430436.
95. Frouge C, Tristant H, Guinebretiere JM, et al. Mammo-
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96. Sloane JP, Mayers MM. Carcinoma and atypical hyperpla-
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tance of lesion size and patient age. Histopathology
1993;23:225231.
44
Breast Biopsy and
Breast-Conserving Surgical
Techniques
Lorraine Tafra, MD and Zandra Cheng, MD
INTRODUCTION
Surgical procedures of the breast have changed signi-
cantly since the late 1990s. With improved imaging
techniques, the detection of radiologic abnormalities is
increasing and the size of detected malignancies is decreas-
ing. These factors have led to a shift in management
strategies toward more precise and aesthetic surgical
approaches. Just as the surgical management has changed,
so have other subspecialty management strategies such
that the multidisciplinary aspect of breast cancer has
become more complex. Comprehensive care, therefore,
involves surgical strategies and decisions with input from
a team of multidisciplinary specialists. The operating sur-
geons rst and crucial step to avoid surgical pitfalls with
the breast patient is to ensure easy and frequent commu-
nication with the other specialists. A strategy used by
many centers to ensure this communication is the multi-
disciplinary tumor board.
A signicant change in breast surgery was the shift from
open surgical biopsy to image-guided needle-core biopsy
(for the diagnosis of breast abnormalities). The current
literature supports the superiority of an image-guided
needle biopsy over an open surgical biopsy for the vast
majority of patients with a breast abnormality.17 This
technology has decreased the frequency of operative pro-
cedures, allowed for tailored care of proven malignancies,
and improved the accuracy of denitive surgical manage-
ment of breast cancer. It is also convenient for the patient
and expedites the diagnosis. A very small group of patients
remain who present with a palpable abnormality, with no
imaging correlate, who will still require an open surgical
biopsy for a denitive diagnosis.
The vast majority of patients who do need to go to the
operating room for a diagnosis (1) are being evaluated for
a nonpalpable, image-detected lesion for which the core
biopsy pathology result is equivocal or (2) were con-
strained by the limitations of the image-guided techniques
(e.g., thin breast, very faint microcalcications).
Partial mastectomy, which is also commonly referred
to as lumpectomy, is the breast-conserving surgical proce-
dure performed for a breast cancer. Although many of
the steps of a lumpectomy are similar to those of a biopsy,
the goals of each are very different and are considered
separately.
Breast Biopsy
INDICATIONS
Patient with a dened mass on palpation but no
evidence of abnormality on mammography or
ultrasound
Patient with an image-detected abnormality who, on
core biopsy, has insufcient tissue for a denitive diag-
nosis, or the benign pathology results are not concor-
dant with imaging ndings
Patient with a benign diagnosis on core biopsy but who
exhibits growth or other concerning symptomatic or
physiologic behavior over time
Patient with an image-detected abnormality who is
not a candidate for image-guided biopsy (presence of
implants, thin breasts, needle phobias, obese [stereo-
tactic tables have a weight limit of about 350 lbs], or
bleeding disorders)
OPERATIVE STEPS
Step 1 Mark palpable lesion in preoperative area
Step 2 Ensure adequate localization if lesion is
nonpalpable
Step 3 Mark incision on breast
Step 4 Resect
Step 5 Palpate lesion resection, perform a specimen
radiograph as indicated, and close
 456 SECTION VI: BREAST SURGERY
OPERATIVE PROCEDURE
Marking the Lesion
Failure to Remove the Correct Area of Concern
Consequence
Occasionally, the patient will have a subtle abnormality;
something the patient can feel well, but for the surgeon,
the abnormality is not well dened. Removing the
wrong area may warrant a return to the operating
room. Besides avoiding the dreaded scenario of doing
a breast biopsy on the wrong breast, marking the site
of the lesion and obtaining consensus on its location
ensure the precise removal of the area of concern.
Grade 3 complication
Prevention
Preoperative discussion of the area, marking and nding
the lesion, and reaching consensus between the surgeon
and the patient on the site of the abnormality.
Adequate Localization
Failure to Remove the Correct Area of Concern
Consequence
Lesions that are not palpable require some form of
localization. This is an active area of investigation
because this scenario continues to increase in fre-
quency.8 Wire localization has been the standard pro-
cedure for localizing a lesion for the surgeon since its
introduction in the 1980s,911 but there is much room
for improvement. Standard wire localization is fre-
quently imprecise. In addition, when addressing a
malignancy, it does not assist with obtaining negative
margins and is not very convenient for the patient who
must endure an additional procedure prior to the initial
surgery. It has typically been performed outside of the
operating room by the radiologist, but fortunately with
increasing use of ultrasound by surgeons, a shift is
occurring, allowing the patient to be localized in the
operating room. Intraoperative localization has many
advantages: it avoids the time delays that come with
coordination of a second department; scheduling is
simplied; patient satisfaction is maximized; staff
inconvenience is minimized; and nally, the accuracy
is probably better when the physician localizing the
lesion is also removing it.
The precision and accuracy of the localization of the
lesion are far more important than who performs it. The
worst consequence of inadequate localization is missing
the lesion and having to return the patient to the operat-
ing room for a second attempt at excision. This is obvi-
ously disconcerting to the patient, but it also delays the
diagnosis and potential treatment. In addition, because
cosmesis is related to the amount of tissue removed, a
second trip to the operating room to remove more tissue
could negatively affect cosmesis, patient satisfaction, and
future imaging.
Grade 3 complication
Prevention
The localization procedure needs to adhere to the
following basic principles, whether performed by the
radiologist or the surgeon:
1. Ensure that the correct area has been targeted, and if a
clip is the target, that the clip has, in fact, remained at
the area of interest since the time of needle biopsy.
2. Ensure that the site of the wire entering the skin has
been marked with a marker visible in the postlocaliza-
tion lms (if the localization is done by someone other
than the surgeon) and that another point of reference
on the breast (most commonly, the nipple) is also
marked so that the surgeon can determine how far the
lesion is from the entry of the wire through the skin and
within the breast tissue.
3. Ensure that the location of the wire is within 2 to 3 mm
of the clip (if a clip is targeted).
4. Ensure that two views (both the craniocaudal [CC] and
the mediolateral [ML]) have been obtained and sent
with the patient to conrm that the locations of the
lesion, the clip, and the wire can be determined by the
surgeon.
Once this has been established, it is the surgeons goal to
remove the area of concern. If the target is a clip or calci-
cations or if the lesion remains nonpalpable even with
dissection down to the area, a specimen radiograph is
needed. If there has been clip migration or if the localiza-
tion is not where the surgeon believes the original lesion
is, it is imperative that good communication occurs
between the radiologist and the surgeon prior to the pro-
cedure. In these cases, retrieval of the clip on specimen
radiograph may not be necessary. If the lesion becomes
palpable with dissection, a specimen radiograph need not
be performed if the operating surgeon is condent the
lesion has been obtained. Caution should be exercised with
this approach, however, because a palpable hematoma
from the prior core biopsy may masquerade as the lesion.
Once the best determination of the site of the lesion is
made based upon direct review intraoperatively of the
mammographic or ultrasound images, the lesion is marked
and the incision is placed directly over the abnormality.
Occasionally, the more cosmetic periareolar incision is
used, especially if the lesion is in close proximity to the
nipple-areolar complex. Dissection then proceeds toward
the wire. The wire is then delivered into the wound.
Palpation of the tissue surrounding the wire will ensure an
adequate removal of the tissue that needs further assess-
ment. It is worth emphasizing that the incision usually is
not placed at the site of the entrance of the wire to the
skin. If the lesion is localized by the surgeon in the oper-
ating room, the surgeon must have prior, precise knowl-
edge of the lesions location. It is best if the surgeon retains
 44 BREAST BIOPSY AND BREAST-CONSERVING SURGICAL TECHNIQUES
a copy of the ultrasound or mammogram for reference in
the operating room. The use of intraoperative ultrasound
is justiably increasing. If a lesion is visible on ultrasound
and the surgeon has ultrasound skills, localization in the
operating room is easier and safer, requires less time, and
is more convenient for the patient and surgeon.
With experience, localizing a lesion in the operating
room is usually straightforward, but it can be challenging
with small lesions. If the lesion is small (<5 mm), consider-
ation should be given to having the patients breast marked
preoperatively by another physician (surgeon or radiolo-
gist) to get consensus by two physicians of the lesions
location. Sometimes, after a core biopsy, a hematoma is
well visualized, but with time, it resolves, leaving little at
the site of the biopsy. If the surgical procedure is to be
scheduled more than a few weeks after the core biopsy,
consideration should be given to performing a repeat
ultrasound to ensure the surgeon can still visualize the
lesion in the absence of the hematoma. Clips placed at the
time of core biopsy have, in the past, not been echogenic
enough to visualize with ultrasound. However, the newer
clips retain materials around the clip itself that can be seen
by a surgeon experienced with ultrasound. Use of these
types of clips can also increase the number of patients who
are candidates for localization in the operating room.
A number of standard localization devices are on the
market (Kopans [Cook, Bloomington, IN]), Hawkins
(Boston Scientic, Watertown, MA [Fig. 441]), and
Bard (CR Bard, Inc., Covington, GA), but new devices
are being introduced in an attempt to solve the inherent
Hawkins Hawkins II
Figure 441 Hawkins needle localization devices. (Courtesy of Boston Scientic, Watertown, MA.)
457
problems of the traditional needles. The Anchor Guide
(SenoRx, Aliso Viejo, CA [Fig. 442]) is a device that uses
an umbrella baskettype deployment that creates a pal-
pable lesion from a nonpalpable lesion, assisting in local-
ization and resection.12
No device to date has been remarkable enough to gain
wide acceptance in the surgical market. For now, the
particular device used is probably less important than
ensuring that the wire or localization device is placed
accurately.
Incision Placement
Poor Cosmesis and Inadequate Planning for
Mastectomy, if Needed
Consequence
Imprecise placement of the incision will result in more
breast dissection than is necessary. The cosmetic inci-
sions on the breast are generally circumlinear; however,
in the inner and 6 oclock positions, the incision that
results in the best cosmesis remains controversial. Large
incisions placed in other than these orientations can
deform the breast and result in poor cosmesis. Large
incisions in the upper outer quadrant near the axilla
may also negatively affect lymphatic drainage of the
breast, potentially leading to breast lymphedema.
Although the entire lesion needs to be removed,
removing large amounts of breast tissue is rarely indi-
cated and will lead to a poor cosmetic result.
Grade 1 complication
Hawkins III
 458 SECTION VI: BREAST SURGERY
A Missing the Lesion
B or a clip almost always require a specimen radiograph.
Figure 442 A, SenoRx localization device with adjustable
bracketing wires. B, Diagram of the device in the breast. (A and
B, Courtesy of SenoRx, Aliso Viejo, CA.)
Prevention
The surgeon should take time to draw the incision, as
well as the site of the lesion, directly onto the patient.
The size of the incision should be kept to the minimum
size that still allows adequate retrieval of the targeted
lesion as well as palpation and visualization of the cavity
for hemostasis. Usually, this is not more than 3 to 4 cm
in length. The nipple and entry of the wire can serve
as useful points of reference if the lesion is fairly deep
and it is difcult to feel the needle tip. To ensure the
location of the lesion or the direction of the wire,
gently tug on the wire and palpate the breast simultane-
ously. Usually, the incision is not placed where the wire
enters the skin and, if placed by the radiologist, can
enter the skin quite a distance from the lesion.
Resection
Hematoma and Poor Cosmesis
Consequence and Prevention
Few complications occur during resection or after a
breast biopsy. The most common are hematoma, infec-
tion, and poor cosmesis. The breast is not tolerant of
bleeding, and meticulous hemostasis should be the
rule. The biopsy cavity should be carefully inspected
and be perfectly hemostatic prior to closure of the
wound. Poor cosmesis should not occur after a breast
biopsy. The amount of tissue needed for a diagnosis is
rarely a large amount and, therefore, should not result
in a deformity of the breast.
Little data are available on the cosmetic outcome of a
breast biopsy and the factors that may affect the appear-
ance of the breast. The prevailing philosophy is that the
cosmesis varies inversely with the amount of tissue resected
and will be worse if deep sutures are placed into the biopsy
cavity, leading to breast contour deformity.
Grade 2 complication
Palpate Lesion Resected, Perform Specimen
Radiograph, and Close
Consequence
Every effort should be made to ensure the lesion has
been adequately sampled for histologic examination, to
avoid having to return to the operating room.
Grade 3 complication
Prevention
Small lesions can often be palpated, obviating the need
for a specimen radiograph. Patients with calcications
Occasionally, the minute clip can be visualized or the
hematoma from the biopsy can easily be palpated. Even
in these circumstances, it is reassuring to see the calci-
cations in the specimen. Clinical judgment is needed
if the surgeon does not see the clip on the specimen
radiograph. The questions that should be considered
include (1) Was the correct site targeted? or (2) Did
the clip fall out during surgical excision? Blind re-resec-
tion if the area is believed to be close to the surgical
site of dissection is warranted; however, extensive dis-
section, which could deform the breast, should be
avoided. Meticulous cosmetic closure of the breast
should be the rule.
Partial Mastectomy
INDICATIONS
Patient with a diagnosed breast cancer who does not
have
 44 BREAST BIOPSY AND BREAST-CONSERVING SURGICAL TECHNIQUES
A contraindication for radiation therapy
Previous radiation therapy
The presence of widespread local breast disease
Large tumortobreast size ratio (i.e., locally
advanced disease) without prior neoadjuvant therapy
or with contraindications or a poor response to
neoadjuvant therapy
Patient with a phyllodes tumor
LUMPECTOMY STEPS
Step 1 Mark palpable lesion in preoperative area
Step 2 Localization
Step 3 Incision
Step 4 Resection and specimen orientation
Step 5 Palpate lesion resection, perform specimen
radiograph as indicated, and close
OPERATIVE PROCEDURE
Marking the Lesion
See the section on Marking the Lesion, under Breast
Biopsy, earlier.
Adequate Localization
Failure to Remove the Entire Lesion with
a Negative Margin
Consequence
A consequence of inadequate localization and precise
resection is positive or close margins, which usually
requires returning to the operating room. This is usually
well tolerated and can be performed without general
anesthesia, but it is obviously disconcerting to the
patient. Although the same principles for localization
for breast biopsies apply to localization for malignan-
cies, the goals are very different. With localization for
malignancy, the entire extent of the lesion must be
mapped to allow the surgeon to perform an accurate
lumpectomy.
Grade 2 complication
Prevention
The goals of partial mastectomy are to obtain negative
margins and a good cosmetic result. This can be dif-
cult because both goals are poorly dened and there is
no universally acceptable standard. It has been well
established, however, that the status of the margin
affects the local recurrence rate.13
The denition of a negative or adequate margin may
range from no tumor at the margin to 3 to 5 mm of
normal tissue intervening between the tumor and the edge
of the specimen.14 Even with no acceptable standard,
attention to the issue is crucial for good long-term results.
459
Accurate localization of the malignancy and determining
the extent of the malignancy for palpable lesions can assist
in obtaining negative margins, but it does not guarantee
this outcome. The same principles outlined for biopsy are
used for localization of malignancies, with a few additions.
If the patient is found to have a large area of ductal
carcinoma in situ (DCIS) based on imaging, it is helpful
to use bracketing wires to outline the area of disease for
the surgeon.15 Other creative approaches to localizing a
malignancy have included leaving a hematoma behind at
the time of biopsy to mark the site for ultrasound localiza-
tion in the operating room16 and using radioactive seed
localization. This latter technique requires 99Tc injection
or radioactive seed placement at the time of the biopsy.
The gamma probe (commonly being used for sentinel
node biopsy) can then be used to track the site of the
malignancy.17
Incision
The principles for incision placement remain the same for
lumpectomy as they do for a biopsy (see earlier). Although
the incision may need to be larger than a biopsy incision,
the procedure can usually be carried out through an inci-
sion half the size of the specimen (Fig. 443). The largest
dimension of the specimen can usually be predicted to be
2 cm plus the size of the tumor in centimeters. Therefore,
a 2-cm malignancy can be removed through a 2-cm
incision. Closure of dead space can deform the breast.
However, if a large amount of dead space is present, the
area may also retract down or deform secondary to radia-
tion and still cause a signicant defect in the contour of
the breast. Recently, oncoplastic strategies have been
introduced to rotate breast tissue into the area of the
defect to minimize the defect.1820 However, this can affect
the area of the radiation boost. Therefore, marking the
boundaries of the original lumpectomy with clips or radi-
opaque markers is important for patients eligible for
radiation therapy after breast conservation.
It is hopeful that in the future, techniques will be devel-
oped to maintain the exact contour of the breast, even
after a large lumpectomy.
Resection and Orientation of the Specimen
Failure to Obtain Negative Margins; Failure to
Orient the Specimen
Consequence
Similar to the localization step, the steps followed for
the surgical resection of a malignancy should decrease
the chance of a positive margin, but with our current
technology, this unfortunate result cannot be elimi-
nated altogether. A second important pitfall after resec-
tion of the tumor is failing to orient the specimen.
Without adequate orientation of the partial mastec-
tomy specimen, a targeted re-resection, if needed,
cannot be done. If the patient is found to have positive
 460 SECTION VI: BREAST SURGERY
A tumors <1.7 cm). This study, perhaps better than any
B use of ultrasound, particularly for ultrasound-visible
Figure 443 A and B, Partial mastectomy performed through a
small incision.
margins and it is not clear which specic margin
is involved, the patient is subjected to excision of
all margins, leading to a potentially poor cosmetic
outcome. In this situation, it is possible that the only
cosmetically acceptable choice is a mastectomy.
Grade 2/3 complication
Prevention
In addition to the techniques described for localization,
other methods can be applied during the resection that
can potentially decrease the reexcision rate of positive
margins. In a few series with small numbers, the use of
intraoperative ultrasound has been shown to decrease
the rate of positive margins.21,22 Intraoperative ultra-
sound can assist in mapping the extension of the tumor
on the breast and in imaging the specimen to guide
further resection of margins deemed to be close.
Frozen section analysis of margin sampling and cytol-
ogy imprinting of the margin have also been used
successfully, although these are criticized for being time
consuming for the pathologist and requiring a long wait
in the operating room for the surgeon.23,24 A recent pro-
spective, randomized trial looked at using a cryoprobe for
localizing ultrasound visible tumors.25 The localization
was accompanied by growing an ice ball template around
the tumor with the hope of obtaining a more accurate
lumpectomy.25 The amount of tissue resected was
decreased compared with that in the group that under-
went standard needle localization. However, the positive
margin rate remained high (30%) in both groups. This
relatively high rate occurred despite well-selected patients
(inltrating ductal tumors [no inltrating lobular], all
other, has elucidated the fact that our current imaging
technology fails to accurately visualize the extent of breast
malignancies in a signicant number of patients.
Precautions need to be taken with the handling of the
specimen itself. Specimen handling can result in false-
positive margins for a number of reasons.26 Specimen
compression for needle wirelocalized specimens can lead
to false-positive margins and should be avoided.27 Other
reasons for false-positive margins include seepage of ink
into crevices of the specimen, fatty tissue surrounding the
tumor that tends to separate from the tumor, and retrac-
tion artifact.
If the chance of a positive margin is to be minimized,
the operating surgeon should develop some strategy that
works for him or her to use on all patients undergoing a
lumpectomy. The surgeon should consider: (1) frequent
tumors, to locate the tumor in the operating room; (2)
liberal use of bracketing wires for large areas of calcica-
tions believed to represent extension of DCIS; (3) fre-
quent use of ultrasound to evaluate the partial mastectomy
specimen; (4) orienting the surgical specimen; (5) obtain-
ing and reviewing the oriented specimen radiograph28;
and (6) avoiding compression.
Although the goal in breast conservation is also to
maintain cosmesis, little data are available that guide the
surgeon as to what actually is an acceptable cosmetic result
(Fig. 444). To compound this, it has now been appreci-
ated that the concordance between the surgeon and the
patient with respect to the postoperative appearance of the
breast is poor.29 Thus, what we, as surgeons, may view as
terrible results may be viewed by the patient as acceptable
and vice versa. Studies are needed to better dene cosme-
sis after lumpectomy from both the surgeons and the
patients point of view, immediately postoperative and
long term.
To not orient the lumpectomy specimen is to possibly
commit the patient to more extensive breast surgery than
might be required. There are many methods of specimen
orientation including suture marking, using prexed tags
to identify the various margins of the tissue, and painting
 44 BREAST BIOPSY AND BREAST-CONSERVING SURGICAL TECHNIQUES 461

C
Figure 444 AC, Examples of a poor cosmetic result after a
lumpectomy.

B
Figure 445 A and B, Faxitron device for intraoperative speci-
men evaluation. (A and B, Courtesy of Faxitron, X-Ray Corp.,
Wheeling, IL.)
 462 SECTION VI: BREAST SURGERY
intraoperatively with pathology dyes by the surgeon. The
exact method chosen is probably less important than the
practice of using the same method on all patients and
frequently communicating with the pathologist on devia-
tions from that method.
Cavity and Specimen Palpation, Specimen
Radiograph if Needed, and Skin Closure
Leaving Tumor in the Breast and a Poor
Cosmetic Outcome
Consequence
Failure to palpate the resected specimen or the cavity
or to view the specimen radiograph could result in
leaving tumor behind. Closing the skin with staples or
placing large sutures for closure can result in visible
hash marks that do not always fade with time.
Grade 2/3 complication
Prevention
After the breast specimen is removed, both the speci-
men and the cavity should be meticulously examined
for residual tumor. However, this must be balanced
with the temptation to perform extensive reexcisions,
leading to poorer cosmetic results. For breast patients,
in whom the issue of cosmesis is a relatively high prior-
ity, it is recommended to perform a cosmetic subcu-
ticular closure, which can leave the breast with an
excellent cosmetic outcome.
Performing a specimen radiograph can also help deter-
mine how close the margins may be and is especially
important for DCIS and the presence of calcications.
This can be very inconvenient if the radiology department
or the mammography suite is not located adjacent to the
operating room (which it rarely is). An exciting new device
to enter the market is a digital specimen radiograph device
(Faxitron, X-Ray Corp., Wheeling, IL [Fig. 445]) that
is portable and can be rolled from one operating room to
another. More data are becoming available on the use of
this device, but it is anticipated that this should make
intraoperative conrmation less time consuming.30
REFERENCES
1. Hatmaker AR, Donahue RM, Tarpley JL, Pearson AS.
Cost-effective use of breast biopsy techniques in a
Veterans health care system. Am J Surg 2006;192:e37
e41.
2. Silverstein MJ, Lagios MD, Recht A, et al. Image-detected
breast cancer: state of the art diagnosis and treatment. J
Am Coll Surg 2005;201:586597.
3. Sauer G, Deissler H, Strunz K, et al. Ultrasound-guided
large-core needle biopsies of breast lesions: analysis of 962
cases to determine the number of samples for reliable
tumour classication. Br J Cancer 2005;92:231235.
4. Groenewoud JH, Pijnappel RM, van den Akker-Van
Marle ME, et al. Cost-effectiveness of stereotactic large-
core needle biopsy for nonpalpable breast lesions
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383392.
5. Verkooijen HM, and the Core Biopsy after Radiological
Localization (COBRA) Study Group. Diagnostic accuracy
of stereotactic large-core needle biopsy for nonpalpable
breast disease: results of a multicenter prospective study
with 95% surgical conrmation. Int J Cancer 2002;99:
853859.
6. Smyczek-Gargya B, Krainick U, Mller-Schimpe M,
et al. Large-core needle biopsy for diagnosis and treat-
ment of breast lesions. Arch Gynecol Obstet 2002;266:
198200.
7. Pijnappel RM, van den Donk M, Holland R, et al.
Diagnostic accuracy for different strategies of image-
guided breast intervention in cases of nonpalpable breast
lesions. Br J Cancer 2004;90:595600.
8. Coburn NG, Chung MA, Fulton J, et al. Decreased breast
cancer tumor size, stage, and mortality in Rhode Island:
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9. Rissanen TJ, Makarainen HP, Mattila SI, et al. Wire
localized biopsy of breast lesions: a review of 425 cases
found in screening or clinical mammography. Clin Radiol
1993;47:1422.
10. Vuorela AL, Ahonen A. Preoperative stereotactic hookwire
localization of nonpalpable breast lesions with and without
the use of a further stereotactic check lm. Anticancer Res
2000;20:12771279.
11. Homer MJ. Nonpalpable breast lesion localization using a
curved-end retractable wire. Radiology 1985;157:259
260.
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randomized, multicenter clinical trial to evaluate the safety
and effectiveness of a new lesion localization device. Am J
Surg 2002;184:318321.
13. Aziz D, Rawlinson E, Narod SA, et al. The role of re-
excision for positive margins in optimizing local disease
control after breast-conserving surgery for cancer. Breast J
2006;12:331.
14. Taghian A, Mohiuddin M, Jagsi R, et al. Current percep-
tions regarding surgical margin status after breast-
conserving therapy: results of a survey. Ann Surg 2005;
241:629639.
15. Liberman L, Kaplan J, Van Zee KJ. Bracketing wires for
preoperative breast needle localization. AJR Am J Roent-
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16. Smith LF, Rubio IT, Henry-Tillman R, et al. Hematoma-
directed ultrasound-guided breast biopsy. Ann Surg 2001;
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17. Gray RJ, Salud C, Nguyen K, et al. Randomized prospec-
tive evaluation of a novel technique for biopsy or lumpec-
tomy of nonpalpable breast lesions: radioactive seed versus
wire localization. Ann Surg Oncol 2001;8:711715.
18. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic
approaches to partial mastectomy: an overview of volume-
displacement techniques. Lancet Oncol 2005;6:145157.
19. Choi JY, Alderman AK, Newman LA. Aesthetic and
reconstruction considerations in oncologic breast surgery.
J Am Coll Surg 2006;202:943952.
20. Masetti R, Di Leone A, Franceschini G, et al. Oncoplastic
techniques in the conservative surgical treatment of breast
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cancer: an overview. Breast J 2006;12(5 suppl 2):S174
S180.
21. Moore MM, Whitney LA, Cerilli L, et al. Intraoperative
ultrasound is associated with clear lumpectomy margins
for palpable inltrating ductal breast cancer. Ann Surg
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22. Rahusen FD, Bremers AJ, Fabry HF, et al. Ultrasound-
guided lumpectomy of nonpalpable breast cancer versus
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23. Cendn JC, Coco D, Copeland EM. Accuracy of intraop-
erative frozen-section analysis of breast cancer lumpec-
tomy-bed margins. J Am Coll Surg 2005;201:194198.
24. Hakam A, Khin N. Intraoperative imprint cytology in
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28. McCormick JT, Keleher AJ, Tikhomirov VB, et al.
Analysis of the use of specimen mammography in
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45
Axillary Surgery
Sara A. Bloom, MD and
Donna-Marie Manasseh, MD

INTRODUCTION accumulated experience, accurately predicting axillary

status in 95.6% of patients. Krag and associates used unl-
Although breast cancer surgery can be traced back to AD tered technetium sulfur colloid to identify the sentinel
200, it was not until the early 18th century that French node in 82% of patients, accurately predicting each case.
surgeon Jean Louis Petit rst noted the signicance of Albertini and colleagues11 utilized both isosulfan blue dye
enlarged axillary nodes and that they should be removed and technetium sulfur colloid, identifying a sentinel node
along with the diseased breast tissue.1 Axillary metastasis in 92% of patients.
has since been shown to be the most important prognos-
tic indicator of both patient survival2 and breast cancer
recurrence.3 Therefore, axillary surgery is a crucial step in Axillary Dissection
the proper management of patients with carcinoma of the
breast. INDICATIONS
William Halsteds4 revolutionary radical mastectomy
excised all three levels of axillary nodes as well as the breast Invasive carcinoma with positive sentinel node
and pectoralis major. This effectively eliminated all regional Inability to identify a sentinel node in an invasive car-
diseased tissue, but at the cost of great deformity to the cinoma patient
patient. Subsequent management of both the breast and Breast cancer with a clinically positive axilla (palpable
the axilla has trended toward conservation of as much nodes)
nondiseased tissue as possible. Today, an axillary dissec-
Operative Steps
tion removes most of the level I and II nodes. The extent
of this dissection has been shown to be sufcient enough Step 1 Incision
to reduce local recurrence, stage the patients level of Step 2 Axillary dissection and identication of struc-
disease, and determine the most effective treatment.5 tures: axillary vein, long thoracic nerve, thora-
Level III nodes are removed only if palpable or otherwise codorsal nerve, intercostobrachial nerves
suspected of containing malignancy. Step 3 En-bloc removal of level I and II nodes
Seventy percent of patients with a clinically negative Step 4 Palpation and possible excision of level III and
axilla will also prove to be microscopically free of axillary Rotters nodes
metastases.6 Axillary dissection carries signicant long- Step 5 Acquisition of hemostasis
term morbidity for these patients. The advent of the sen- Step 6 Drain placement
tinel lymph node biopsy (SLNB), rst successfully applied Step 7 Two-layer closure
by Morton and colleagues7 for use in melanoma surgery,
has allowed node-negative patients to be spared complete OPERATIVE PROCEDURE
axillary dissection. When compared with axillary dissec-
tion, SLNB results in less postoperative morbidity (arm Incision
numbness and swelling) and allows for faster recovery.8
Inappropriate Placement of Incision
The sentinel lymph node is dened as the rst lymph node
to which a primary tumor will drain. In breast cancer, this Consequence
is typically a level I node. Wound contraction and breast deformity.
SLNB can reliably predict the status of a regional lymph Grade 1 complication
node basin. Giuliano and coworkers9 and Krag and associ-
ates10 applied this technique to breast cancer. Giuliano and Prevention
coworkers used isosulfan blue dye to localize the sentinel If the patient will be undergoing a tissue-sparing pro-
node in 65.5% of patients. The rate improved to 78% with cedure of the breast, a separate U-shaped or oblique
 466 SECTION VI: BREAST SURGERY

Axillary vein

Pectoralis
major
Intercostal-brachial
nerve

Thoracodorsal
nerve

Long thoracic Intercostal-brachial

nerve nerve

Latissimus Thoracodorsal nerve

dorsi Serratus
anterior
Long thoracic nerve

Figure 451 Axillary anatomy.

incision from the lateral border of the pectoralis major

to the anterior border of the latissimus dorsi, just infe-
rior to the hairline, gives the best exposure and cos-
metic result. The incision should not be visible from
the frontal view of the patient. Radial or angled inci-
sions and those that are continuous with the breast
excision site result in more deformity of the breast
owing to wound contraction during the healing
process.
Axillary Dissection and Identication of
Pertinent Nerves and Blood Vessels (Fig. 451)
Nerve Damage
Consequence
Multiple nerves course through the axilla (Fig. 452),
damage to which causes the following patient
morbidities:
Damage to the long thoracic nerve, which inner-
vates the serratus anterior, causes winging of the
scapula, shoulder pain, and inability to raise the arm
above shoulder level.
Damage to the thoracodorsal nerve, which inner-
vates the latissimus dorsi, causes weakened arm
pullups and adduction.
Damage to the intercostobrachial nerves causes
numbness and pain of the upper inner arm. These
are the most commonly damaged nerves of an axil-
lary dissection because they course through the axil-
lary space and must sometimes be sacriced with the
specimen.
Medial Lateral
Figure 452 Nerves of the axilla.
Damage to the lateral pectoral nerve, which inner-
vates the pectoralis major, causes muscle atrophy
and limitation of shoulder motion.
Grade 13 complication
Repair
Typically, there is no repair for injury to these nerves.
Some improvement does occur with time, especially
with regard to sensory dysfunction. Although 76.5% of
axillary dissection patients studied by Roses and cowork-
ers12 initially complained of medial arm/axillary numb-
ness or paresthesias, 82% of these had resolution of
symptoms on follow-up assessment.
Recovery is less likely with damage to the motor nerves.
On long-term follow-up of patients with injury to the long
thoracic nerve, 81% cannot lift or pull heavy objects, 58%
cannot play sports (such as tennis or golf), and 54% are
unable to work with their hands above shoulder level.13
Attempts have been made to surgically restore normal
scapulohumeral dynamics in cases of serratus anterior
paralysis by transferring the pectoralis major tendon14 or
xing the inferior angle of the scapula.15 These therapies
are still experimental and, if they prove successful, may be
applied more readily in the future.
The overall incidence of motor nerve damage secondary
to axillary dissection is not well reported. It appears to be
so low that the most common presentation in the litera-
ture is in case report format.

Axillary vein
Thoracodorsal
nerve
Intercostal-brachial
nerve
Medial Lateral
Figure 453 Operative anatomy of the axilla.
Prevention
All major nerves should be identied and preserved. As
the dissection proceeds inferiorly from the axillary vein
(Fig. 453), the long thoracic nerve of Bell should be
identied coursing longitudinally along the investing
fascia of the chest wall anterior to the subscapularis
muscle and inserting into the serratus anterior. It passes
approximately 2 cm deep to where the intercostobra-
chial nerve exits the chest wall. It should be separated
from the specimen and allowed to remain against the
chest wall. The thoracodorsal nerve should be identi-
ed deep in the axilla, alongside the subscapular vessels,
traversing laterally and inferiorly toward the latissimus
dorsi. The intercostobrachial nerves course transversely
through the axilla, and although not always possible,
an attempt should be made to spare these nerves. An
attempt should also be made to preserve the pectoral
neurovascular bundle as it passes laterally around the
pectoralis major, inferior to the axillary vein. Use of
cautery should be limited in the axilla, because it can
transmit and cause damage to these nerves. Use clips
and ties as necessary.
Lymphedema
Consequence
Breast cancer patients frequently develop upper extrem-
ity lymphedema, distal to the site of axillary dissection.
It is due to an overload of the lymphatic system, which
can no longer adequately remove the amount of lymph
made by the tissue. This problem is then compounded
by an accumulation of macromolecules, causing
increased oncotic pressure and, subsequently, more
tissue edema. This stagnant, protein-rich uid can invite
further complications of cellulitis and lymphangitis.
It is difcult to precisely dene the incidence of lymph-
edema. In a review of the literature, lymphedema occurred
in 6% to 30% of patients.16 It should be noted that these
studies varied in length of follow-up from 14 months to
11 years and that the incidence of lymphedema clearly
45 AXILLARY SURGERY 467
increased with longer patient follow-up. Petrek and asso-
ciates17 studied a cohort of breast cancer survivors at 20
years after surgery and found that 49% reported the sensa-
tion of lymphedema. Although most of these patients
(77%) developed this complication within the rst 3 years,
additional patients developed lymphedema at a rate of
approximately 1% per year.
Grade 3 complication
Repair
No surgical repair is possible. Patients can undergo
physical therapy and may wrap the affected arm with
compressive dressings to decrease swelling.
Prevention
Risk factors for the development of lymphedema
include the extent of the dissection (particularly near
the axillary vein), number of nodes removed, postop-
erative radiotherapy, obesity, and arm infection or
trauma.1719 In Petrek and associates study,17 the late-
onset lymphedema was associated with a postsurgery
history of arm infection/injury or weight gain. The
surgeon has little control over many of these factors
but can be careful not to strip the axillary vein of its
overlying tissue. The patient can reduce risk factors by
controlling postoperative weight gain and arm injury/
infection.
Dissection above the Axillary Vein
Consequence
Extension of the dissection above the level of the axil-
lary vein increases the likelihood of damage to the
axillary vein, axillary artery, or brachial plexus.
Grade 2 complication
Repair
The repair should be tailored to the specic structure
injured.
Prevention
The dissection should proceed from the lateral border
of the pectoralis major and minor to the anterior
border of the latissimus dorsi, maintaining a superior
border 1 cm below the axillary vein.
Acquisition of Hemostasis
Lack of Hemostasis
Consequence
Hematoma will form in the cavity created by the excised
tissue.
Grade 1 or 2b complication
Repair
The hematoma may be treated by percutaneous
drainage in the ofce or, if there is persistent bleeding,
may need a return to the operating room to ligate the
bleeding vessel.
 468 SECTION VI: BREAST SURGERY
Prevention
Ensure excellent hemostasis prior to closure.
Drain Placement
Inadequate or Failure of Drain Placement
Consequence
Seromas are the most common complication of axillary
surgery, resulting from disruption of both capillary and
lymphatic vessels. The exact incidence varies wildly
from study to study (range 4%92%), based on the
authors classication criteria.5,2022 Serous uid natu-
rally collects in the excision cavity and can be identied
sonographically in 92% of patients.21 It is when these
seromas become large enough to require aspiration
(42%) that they can lead to further infection, ap
necrosis, wound dehiscence, nerve injury, and an
increased incidence of arm lymphedema.2326
Grade 1 complication
Repair
Seromas are typically treated in the ofce by percutane-
ous aspiration.
Prevention
The use of a closed suction drain does not necessarily
prevent seromas, but it is believed to decrease the
degree and subsequent complications of seroma forma-
tion.27 Divino and colleagues28 found that the use of
drains decreased the rate of axillary seroma formation
from 40% to 6%. Kopelman and coworkers29 noted a
decrease in seroma formation if the drain was left until
there was less than 35 ml of drainage over 24 hours.
Generally, a closed suction drain should be placed infe-
rior to the incision through a separate stab incision and
should be removed when the output has decreased to
30 to 40 ml per 24-hour period.
Attempts have been made to use brin glue to decrease
seroma formation.30,31 The results have been mixed, and
more investigation into this potential therapy is still
needed.
Risk factors for seroma formation include increased age,
patient weight, amount of drainage in the rst 72 hours,
a large number of positive nodes, and no previous surgical
biopsy.32,33 Although there have been reports to the con-
trary, Petrek and associates33 found no increase in seroma
formation with early arm mobilization.
Sentinel Lymph
Node Biopsy
INDICATIONS 34
T1 or T2 invasive carcinoma of the breast, with clini-
cally negative lymph nodes
Cases of ductal carcinoma in situ (DCIS) that are
aggressive, widespread, and palpable, requiring mastec-
tomy or when immediate reconstruction is to be
performed
CONTRAINDICATIONS 34
Large and locally advanced (>5 cm) invasive breast
carcinoma.
RELATIVE CONTRAINDICATIONS
Previous Axillary Surgery
Although a history of axillary surgery has previously been
viewed as a contraindication to SLNB, some studies
support the use of SLNB even if the patient has previously
undergone an axillary dissection. Port and colleagues35
reported a 75% success rate in identifying sentinel nodes
in patients with previous axillary surgery. The success rate
was higher if fewer than 10 lymph nodes were removed
previously (87%) versus removal of 10 or more nodes
(44%). In these cases, the sentinel node may map to the
internal mammary or contralateral axillary lymph node
basins.36 In patients with a history of axillary surgery,
SLNB may be attempted, and it may be advantageous to
perform preoperative lymphoscintigraphy.
Clinically Positive Axillary Nodes
Any clinically positive lymph node, identied either pre-
operatively or during surgery, is also considered a sentinel
lymph node and should therefore be excised. Although
some surgeons may advocate proceeding with an axillary
dissection, 25% of clinically positive nodes yield false-
positive ndings.34 The use of blue or radiolabeled dye
may help identify additional sentinel nodes. If all of these
nodes return negative for cancer, these patients can be
spared the morbidity of an axillary dissection.
Inammatory Breast Cancer34
SLNB false-negative rate may be elevated owing to sub-
dermal lymphatics that are partially obstructed or contain
tumor emboli.
Multicentric Tumors34
Many surgeons exclude patients with multicentric disease;
however, several nonrandomized studies have shown that
intradermal or subareolar injection yields comparable
results to SLNB in women with unifocal disease.
Allergy to the Dye34
Avoid blue dye, and use radiolabeled colloid.

Pregnancy
Vital dyes should not be used. However, when using
radiolabeled colloids, the dose of radiation received by the
fetus is minimal and most likely safe for use.
Preoperative Radiation or Chemotherapy
At this time, data are insufcient to recommend use of
SLNB in this setting.
Recent Reduction Mammoplasty
Data are insufcient, but it is believed that the more
extensive the prior surgery, the higher the likelihood of
false-negatives or SLNB failure.
OPERATIVE STEPS
Step 1 Injection of dye and/or radioisotope
Step 2 Incision
Step 3 Dissection and identication of sentinel node
Step 4 Excision of sentinel node
Step 5 Inspect for palpable nodes
Step 6 Acquisition of hemostasis
Step 7 Closure
OPERATIVE PROCEDURE
Injection of Dye and/or Radioisotope
Allergic Reaction
Consequence
Approximately 1% of patients have allergic reactions to
the isosulfan blue dye that is used in sentinel lymph
node biopsies. The dye has been associated with severe
anaphylactic reactions, requiring vigorous resuscita-
tion.37,38 The reaction typically occurs 15 to 30 minutes
after injection. It is diagnosed by a combination of
cardiovascular collaspse, erythema, angioedema, bron-
chospasm, urticaria, and/or pulmonary edema, second-
ary to massive histamine release. Less severe allergic
reactions have also been reported, consisting of blue
hives (diffuse, blue, maculopapular rashes) without
anaphylaxis.39
Grade 2 complication
Repair
Anaphylaxis should be aggressively treated with
uid resuscitation and medications as necessary.38 As a
rst line of therapy, the anesthetic agents are stopped,
and the patient is treated with 100% oxygen, large
volumes of intravenous uid, and epinephrine. The
second line of therapy consists of H1-blockers and cor-
ticosteroids. If the hypotension is refractory, patients
45 AXILLARY SURGERY 469
can then be given -blockers and glucagon. These
patients may experience recurrent episodes of hypoten-
sion and should, therefore, be admitted for 24-hour
observation.
Blue urticaria is treated like other type I hypersensitivity
reactions, with intravenous hydrocortisone and diphen-
hydromine. The urticaria regresses within 24 hours and is
typically gone within a week.
Prevention
Isosulfan is identical in chemical structure to substances
used in cosmetics and hand lotions as well as other
household products. Exposure to these products has
led to sensitization of approximately 3% of the popula-
tion, as determined by skin-prick testing.40 Although
skin-prick testing could determine who is at risk for
anaphylaxis from isosulphan, it is not routinely prac-
ticed. Ultimately, SLNB should be performed only in
a setting in which the personnel is able to recognize
and treat anaphylaxis.
Articial Decrease in Pulse Oximeter Reading
Of note: The blue dye causes a pseudodesaturation, fre-
quently decreasing the reading of the pulse oximeter by
1% to 2%.37 The saturation may appear to be low, but the
arterial PO2 remains within normal limits.
Dissection (Figs. 454 and 455)
Nerve Damage
Patients report sensory decits after SLNB that are
approximately half of those reported by axillary dissection
patients.41 This is secondary to damage to branches of the
intercostobrachial nerves (as explained previously in this
chapter). Most cases improve within 3 months.
Grade 1 complication
Seroma/Lymphedema
The dissection required to identify and excise the sentinel
node can lead to complications such as seroma formation
Site of dye injection
(peritumoral)
Previous incision
Clavipectoral
Sentinel lymph node fascia
Figure 454 Sentinel lymph node biopsy: the injection site of the
blue dye and its migration to the sentinel lymph node.
 470 SECTION VI: BREAST SURGERY
Blue node
Blue lymphatic
Figure 455 Sentinel lymph node biopsy: a blue lymphatic leading
to the sentinel lymph node.
and lymphedema, as discussed previously. The minimal
amount of dissection (as compared with axillary dissec-
tion), makes lymphedema an uncommon complication of
SLNB. Sener and colleagues42 noted only a 3% incidence
of lymphedema in patients who underwent SLNB com-
pared with a 17% incidence in patients who had SLNB
followed by axillary dissection. They also noted for most
of these patients that the mass was located in the upper
outer quadrant. The incidence and severity of seroma
formation after SLNB are not typically great enough to
warrant drain placement.
Grade 13 complication
Excision of Sentinel Node
Failed Sentinel Node
Consequence
If the surgeon is unable to nd a sentinel node, she
or he must proceed to an axillary dissection. This inicts
upon the patient the morbidity associated with axillary
dissection, even if no positive nodes are ultimately
identied.
Grade 2 complication
Repair
A failed SLNB necessitates an axillary node
dissection.
Prevention
The choice of lymphatic tracer inuences the false-
negative rate. A review of the literature found sentinel
node identication rates to be 81% for blue dye, 92%
for radioisotope, and 93% for a combined method.43
SLNB has been less successful in older patients and
obese patients.44 As patients age, nodal tissue is replaced
by increasing amounts of adipose tissue. For older
patients, success of the SLNB is somewhat improved
by the combined technique.45
When using blue dye, 2 to 5 ml is injected 5 minutes
prior to incision. The injection can be peritumoral, intra-
dermal, retroareolar, or some combination of these. The
breast is massaged from the site of injection toward the
axilla to enhance the lymphatic migration of the dye.
When using radiocolloid, injection is made anywhere from
2 to 24 hours prior to the incision. Lymphoscintigraphy
can be performed, but it has not been shown to improve
results.46 The background gamma probe count, taken
after nodal excision, should be less than 10% of the highest
node count.10
Although there is high concordance between intrader-
mal and peritumoral injection,47 an analysis of 966 patients
performed at Memorial Sloan-Kettering showed that
intradermal injection is associated with a higher success
rate.48 McMasters and coworkers49 also showed better
results with the dermal technique, identifying sentinel
nodes in 98% of dermal injections compared with 89.9%
of peritumoral injections. This is likely due to the high
density of lymphatic vessels in the skin. Peritumoral injec-
tion has been found to be more accurate for localizing
nonaxillary sentinel nodes; however, the likelihood of
having nonaxillary metastases without having a positive
axillary node is very low.43
False-Negative Node
Consequence
A false-negative node is either (1) a negative sentinel
node with subsequent discovery (by backup axillary
dissection) of positive nodes elsewhere in the axilla
or (2) a node found negative by frozen section but
subsequently positive by further microscopic studies.
The false-negative node can lead to the downstaging
of the patients disease and failure to implement the
appropriate adjuvant therapy. Residual tumor is left in
the patients axilla, increasing the likelihood of local
recurrence.
Grade 13 complication
Repair
Studies are unclear about returning to the operating
room for axillary dissection if a node found negative by
frozen section ultimately reveals micrometastases. Radi-
ation has been suggested as an alternative therapy, but
at this time, data are insufcient on the subject. There-
fore, the current recommendation is to proceed with
axillary dissection.6,43
Prevention
The choice of lymphatic tracer inuences the false-
negative rate. In a review of the literature, false-
negative rates were 9% for blue dye, 7% for radioisotope,
and 5% for a combination method.43 The combined
method may decrease false-negative rates owing to the
increased removal of multiple sentinel nodes.49 The
false-negative rate decreases from 14.3% to 4.3% when

multiple sentinel nodes are removed instead of one, and
the only factor independently associated with identi-
cation of a single sentinel node is the use of blue dye
alone.50
More importantly, the experience of the surgeon is
directly related to the false-negative rate. Most false-
negative results occur in a surgeons rst 15 cases and are,
therefore, best prevented by increased experience of the
surgeon.51 Location of the tumor in the lateral half of the
breast may increase the false-negative rate when radiocol-
loid is used, secondary to masking of true sentinel nodes
situated close to the site of injection.52 Contrary to initial
thoughts, a previous excisional biopsy does not increase
the likelihood of a false-negative node.53
It is also important to palpate the axilla for abnormal
nodes throughout surgery. A node with a high amount of
tissue replacement by tumor cells may not have good
uptake of the dye.
For both failed and false-negative SLNB: McMasters
and associates54 showed that sentinel lymph node identi-
cation and false-negative rates are greatly improved after
a surgeons rst 20 cases. Surgeons new to SLNB should
perform backup axillary dissections to validate their results.
This means a training period of 20 to 30 SLNBs with
subsequent axillary dissection, conrming an identica-
tion rate greater than 90% and a false-negative rate less
than 5%.6 With more experience, the surgeon should be
able to improve to an identication rate of 95%.55 The
axillary dissection should not be abandoned until the
surgeon can achieve this level of performance.
All palpable lymph nodes are also considered senti-
nel nodes and should be excised in addition to the node(s)
identied by blue dye or radioactive colloid.
Other Complications
Wound Infection
Consequence
Surgical wounds are naturally at risk for infection. The
Axillary Lymphatic Mapping Against Nodal Axillary
Clearance (ALMANAC) trial56 identied a 15% infec-
tion rate for axillary dissection and an 11% rate for
SLNB. The most common organisms identied are
Staphylococcus aureus and Staphylcococcus epidermidis.57
Grade 2a complication
Repair
Treat with the appropriate antibiotic. Open and pack
the wound when indicated.
Prevention
Preoperative antibiotics can decrease the rate of infec-
tion after breast and axillary surgery by 50%.58 However,
most of these cases are associated with a recent previous
biopsy.57,59 Thus, preoperative antibiotics are generally
not required, except in those patients at increased risk
for infection (recent previous open biopsy, alteration of
host defense).
45 AXILLARY SURGERY 471
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31. Moore M, Burak WE, et al. Fibrin sealant reduces the
duration and amount of uid drainage after axillary
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32. Burak WE Jr, Goodman PS, Young DC, Farrar WB.
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33. Petrek JA, Peters MM, Nori S, et al. Axillary lymphad-
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34. Lyman GH, Giuliano AE, Somereld MR, et al. American
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35. Port ER, Fey J, Gemignani ML, et al. Reoperative sentinel
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36. Roumen RMH, Kuijt GP, Liem IH. Lymphatic mapping
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38. Albo D, Wayne JD, Hunt KK, et al. Anaphylactic
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40. Kalimo K, Jansen CT, Kormano M. Sensitivity to patent
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41. Temple LKF, Baron R, Cody HS, et al. Sensory morbidity
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42. Sener SF, Winchester DJ, Martz CH, et al. Lymphedema
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44. Morrow M, Rademaker AW, Bethke KP, et al. Learning
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45. Motomura K, Inaji H, Komoike Y, et al. Combination
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46. McMasters KM, Wong SL, Tuttle TM, et al. Preoperative
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47. Borgstein PJ, Meijer S, Pijpers RJ, van Diest PJ. Func-
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49. McMasters KM, Wong SL, Martin RC, et al. Dermal
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55. Schwartz GF, Giuliano A, Veronesi U, and the Consensus
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45 AXILLARY SURGERY 473
57. Beatty J, Robinson GV, Zaia JA, et al. A prospective
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Obstet 1990;170:12.
46
Mastectomy
Shawna C. Willey, MD and
Elizabeth D. Feldman, MD
INTRODUCTION
Although the trend in surgical management of breast
cancer is toward less extensive surgery, a signicant number
of patients are still not candidates for minimally invasive
procedures who go on to have a mastectomy. Up to
50% of women who are diagnosed with breast cancer
undergo mastectomy as their primary surgical therapy.1
Almost all women with breast cancer are candidates for
mastectomy.
The approach to mastectomy has evolved since William
Halsted2 rst described what is referred to today as
the Halstedian radical mastectomy in 1894. The
Auchincloss modication of the radical mastectomy is
most consistent with the modied radical mastectomy
(MRM) of today, which includes removal of the entire
breast, nipple-areolar complex (NAC), and axillary lymph
nodes (levels I, II, and occasionally, III if involved) with
preservation of both pectoralis muscles.3
Further modication of the MRM occurred with the
development of the total mastectomy, which preserves the
axillary lymph nodes as well as both pectoralis muscles.
Based on the premise that breast cancer is a systemic
disease,4 axillary node dissection is not performed if
sentinel lymph node biopsy (SLNB) is negative, because
it is unlikely to affect survival and has associated
morbidity.5
In addition, skin-sparing mastectomy (SSM) has
emerged as another approach to surgical therapy for breast
cancer since its rst description by Toth and Lappert in
1991.6 SSM involves the removal of breast parenchyma,
the NAC, previous biopsy sites, and skin in close
proximity to the lesion and preserves the breast envelope,
which facilitates the cosmetic result of the breast
reconstruction.
INDICATIONS FOR TOTAL
MASTECTOMY
Multicentricity of disease (two or more primary
tumors in separate quadrants) or diffuse malignant
calcications
Persistent positive margins after multiple attempts at
breast-conserving surgical procedures
Recurrence in a breast previously treated with partial
mastectomy and radiation
Tumor size relative to breast size that does not
allow for an acceptable cosmetic outcome for breast
conservation
Contraindication to radiation
Patient preference
The indications for MRM are similar to those for
total mastectomy as they relate to treatment of the
breast. However, an axillary dissection is performed in
conjunction with the mastectomy if a patient has clinically
suspicious axillary disease, circumstances that exclude her
from undergoing an SLNB, or a positive sentinel lymph
node.5
A mastectomy is an operation with low morbidity and
mortality and is well tolerated by patients. However, it is
not without complications including seroma, hemorrhage
and hematoma, wound infection, skin ap necrosis, recur-
rence, and pain syndromes, and rarer complications such
as pneumothorax, chylous stula, and air embolism.
OPERATIVE STEPS
Step 1 Diagnosis with core needle biopsy (when
possible) at two different sites to conrm
multicentricity
Step 2 Incision
Step 3 Flap elevation
Step 4 Extent of dissection
Step 5 Wound closure
Step 6 Postoperative concerns
Preoperative Core Needle Biopsy
Wound Infection
Consequence
Increase in cost, psychological trauma, and cosmetic
consequences. Wound infections result in additional
medical care including prolonged hospitalization,
 476 SECTION VI: BREAST SURGERY

outpatient physician visits, antibiotics, hospital read-

missions, or possible surgical drainage. The rates of
wound infection are reported to range from 2.8% to
15%.79
Grade 1/2 complication
Repair
Antibiotics or, if severe, surgical drainage.
Prevention
Witt and colleagues10 demonstrated that patients who
underwent core needle biopsy within 1 to 3 days of a
denitive surgical procedure were at signicantly higher
risk for developing a wound infection (P = .001).10 This
effect remained constant even with control for potential A
confounders such as age, diabetes, benign versus malig-
nant disease, and preoperative marking. The authors
suggested increasing the interval between core needle
biopsy and denitive surgery but could not recommend
an appropriate interval because most of their patients
underwent surgery within 24 hours of biopsy.
The use of prophylactic antibiotics has not generally
been recommended for clean procedures such as mastec-
tomy. However, in a randomized, double-blind trial of
606 patients undergoing breast surgery (lumpectomy and
MRM) with and without perioperative antibiotic prophy-
laxis, Platt and coworkers11 demonstrated a decrease in
infectious complications from 12.2% to 6.6% in those
treated with cefonicid no more than 90 minutes prior to B
incision.11 There were 51% fewer denite wound infec- Figure 461 A patient with skin ap necrosis after a mastectomy.
tions (dened as a wound with erythema and drainage, A, Far-eld view of a patient with skin ap necrosis after a mastec-
one with purulent drainage, and/or one opened and tomy. B, Close-up view.
reclosed) and the incidence of purulent drainage decreased
by 57%. Staphylococcus aureus was the principal pathogen,
accounting for 78% of all isolates.
Prevention
Factors believed to contribute to necrosis include inad-
Incision equate blood supply to the ap, wound closure under
tension, external pressure from compression dressings,
Skin Flap Necrosis (Fig. 461)
obesity, and type of incision (vertical vs. transverse).
Consequence Hultman and Daiza13 also found that diabetes and a
Local wound care and possible dbridement. The history of radiation as well as increased body mass index
incidence of skin ap necrosis has been estimated to (BMI) were associated with native skin ap complica-
be 11% and is similar in SSM and nonskin-sparing tions. Interestingly, unlike previous reports, recent or
mastectomy.12 active tobacco use did not seem to contribute to ap
Grade 13 complication necrosis.
Vlajcic and colleagues14 described the use of an omega
Repair or inverted omega incision around the NAC in order to
Hultman and Daiza13 recommend conservative man- preserve the mesentery-like horizontal septum of the
agement if possible, including the application of topical breast that carries the main vascular and nerve channeling
antimicrobial creams, minimal dbridement, and the structure of the NAC rst noted by Wuringer and associ-
use of a supportive brassiere.13 For patients with mode- ates in 199815 (Fig. 462). They proposed that periareolar
rate ap loss as evidenced by full-thickness skin necro- or circumareolar incisions were inappropriate for periph-
sis, stable eschars develop and separate in weeks to eral lesions because they mandated tunneling, which can
months, permitting salvage of the aps. Severe ap loss compromise the aps. The horizontal lateral extension of
involving extensive infarction of the skin envelope often the omega can be used for tumors in the lateral hemi-
requires operative intervention after demarcation of sphere of the breast, axillary dissection, and exposure of
ap viability. the thoracodorsal vessels.

12 12
9 3
6 6
A previous excision with positive margins. Laronga and
B
Figure 462 The omega incision constructed both superior and
inferior to the nipple-areolar complex. A, Frontal view. B, Oblique
view.
The dissection of skin aps with a constant thickness
is important in maintaining the viability of the ap. The
application of clamps (Lahey or Adairs) or skin hooks
on the underside of the ap with constant, even tension
by the assistant at right angles to the chest wall allows
visualization of the dissection plane and ap develop-
ment. Similarly, long, even strokes with a cautery or
knife in parallel with the ap contribute to the evenness
of the ap and minimize accidental burns and
buttonholes.
Inability to Reconstruct
Consequence
Diminished cosmetic outcome and psychological
trauma.
Grade 1 complication
Prevention
The choice of incision is dependent both on the loca-
tion of the primary tumor and on the reconstructive
options considered (Fig. 463). Generally, a skin-
sparing incision with adequate margins is used if imme-
diate reconstruction is planned. Conventional SSM
46 MASTECTOMY 477
entails the excision of the NAC and previous biopsy
scars with the preservation of the skin envelope. The
same amount of breast parenchyma is removed. SSM
benets the aesthetic outcomes for all types of recon-
struction in that it preserves or accurately restores the
inframammary fold (IMF), improves shaping of the
breast mound, retains sensibility of the skin envelope,
and uses the breast skin in the nal reconstruction.16
SSM is not indicated in patients with inammatory
carcinoma, large tumors, and locally advanced disease
in which the risk of recurrence is high.17
An SSM generally includes removal of the NAC as well
as all previous biopsy scars, especially if associated with a
coworkers18 showed that nodal positivity, subareolar
tumor location, and multicentricity were signicant risk
factors for NAC involvement. Although these authors
quoted a NAC positivity for occult carcinoma of 5.6%, a
literature review by Cense and colleagues19 found that the
NAC was involved in as many as 58% of mastectomy
specimens. They concluded that the best candidates for
NAC conservation, a new trend in mastectomy, were T1
tumors more than 4 cm from the nipple.
If no reconstruction is planned, a transverse or slightly
oblique elliptical incision is used (see Fig. 463). Vertical
incisions are avoided because they can limit upper extrem-
ity range of motion.
Flap Elevation
Seroma Formation
Consequence
Discomfort, repeated aspiration, and wound infection.
Seroma formation arises from the inammatory exu-
dates and the transection of blood vessels and lymphat-
ics. Some studies have demonstrated an increase in
seroma formation with the use of electrocautery com-
pared with scalpel (38% vs. 13%, P = .01),20 whereas
others have not found a statistically signicant differ-
ence.21,22 Seromas not only can cause discomfort but
also may delay the start of adjuvant therapy.
Grade 1/2 complication
Repair
Treatment may include aspiration or placement of a
drain if repeated aspiration is unsuccessful.
Prevention
The use of a closed suction drain beneath the skin aps
may decrease dead-space and subsequent seromas,
as rst proposed by Murphy in 1947.23 However,
Puttawibul and associates24 demonstrated no statisti-
cally signicant difference in complications in patients
with and without drains in the pectoral area. More
recently, Jain and coworkers25 demonstrated that the
use of suction catheter drainage did not prevent seroma
formation and was associated with prolonged postop-
erative stay and higher postoperative pain scores. In
 478 SECTION VI: BREAST SURGERY
A
Central
B
Upper outer
C
Upper inner
D
Lower outer
E A, Central. B, Upper outer. C, Upper inner.
Lower inner
addition, the incidence and rate of seroma formation
in patients having mastectomy without drainage but
with brin sealant installation were both signicantly
reduced compared with closed drainage as in the stan-
dard technique.
The type of drain placed has also been reviewed. Porter
and colleagues20 noted in their comparison of Jackson-
Pratt to Blake drains that Blake drains were more effective
in reducing seroma formation (P = .006). In addition,
Coveney and associates26 suggested that suturing the skin
aps to the underlying muscle can minimize seroma for-
mation. They found that the incidence of seroma in
patients who underwent closed suction drainage was sig-
nicantly less (P < .05) and there was a decreased number
of seromas in the group that had their aps sutured com-
pared with those that did not.
Figure 463 Creation of an elliptical incision
with respect to the location of the tumor and
margins. The vector of the ellipse is modied to
include the tumor with appropriate margins.
D, Lower outer. E, Lower inner.
Smaller studies have examined the use of the harmonic
scalpel in performing the dissection without direct com-
parison with either electrocautery or scalpel.27,28 It was
postulated that the harmonic scalpel has decreased thermal
injury compared with electrocautery and results in sealing
of vascular and lymphatic channels. Deo and Shukla28
noted a diminished postoperative drain volume in patients
with mastectomies performed with harmonic scalpel com-
pared with conventional mastectomy (430 ml/patient vs.
1100 ml/patient).
In contrast to the studies by Jain and coworkers25 noted
earlier, there have also been studies using intraoperative
brin sealant29 as well as sclerosing agents such as tetracy-
cline to reduce dead space30 that have not demonstrated
statistically signicant decreases in seroma formation com-
pared with control.

The removal of the pectoralis major fascia may also con-
tribute to seroma formation. Dalberg and coworkers31 ran-
domized 247 patients to removal or preservation of the
pectoralis major fascia and did not detect a statistically sig-
nicant difference in seroma formation between groups.
Hemorrhage and Hematoma Formation
Consequence
Anemia, blood transfusion, and wound infection. Blood
transfusion has long been associated with morbidity
and mortality with multiple potential and actual adverse
effects including allergic reactions and transmission of
communicable diseases. The detrimental effect of peri-
operative blood transfusion on survival after operations
for cancer surgery has been reported.3234 The percent
of patients who undergo mastectomy and require blood
transfusion is not consistently reported.
Patients may also suffer from postmastectomy pain
syndrome secondary to axillary hematoma formation.35
This chronic neuropathic pain syndrome is a long-lasting
continuous pain in the axilla, medial upper arm, and
lateral chest wall beginning shortly after surgery. The
pain is characterized as paroxysms of lancinating pain
against a background of burning, aching, and tightening
sensations.3638
Grade 1 complication
Prevention
Several studies have demonstrated statistically signi-
cant increases in intraoperative blood loss as well as
postoperative packed cell volume transfusion in mastec-
tomy performed with scalpel compared with electro-
cautery.21,22 Electrocautery has the principal advantage
of being able to coagulate as it cuts or dissects.
An alternative may be the harmonic scalpel, which uses
high-frequency ultrasonic waves for dissection and hemo-
stasis and has had encouraging results in the laparoscopic
and cardiovascular surgical elds.39,40 It causes breakdown
of hydrogen bonds and forms a protein coagulum to
occlude the vascular and lymphatic channels.28 Again,
multiple small studies have suggested the feasibility of
using the harmonic scalpel for ap dissection, removal of
the breast parenchyma from the pectoralis muscle, and
axillary dissection.27,28 However, direct comparison with
conventional instruments is not yet available, and the
expense related to the instrument may be prohibitive.
Extent of Dissection
Recurrence
Consequence
Chest wall (68%) and supraclavicular nodes (41%) were
the most common sites of locoregional recurrence in a
review of 1031 patients who were treated with mastec-
tomy and doxorubicin-based chemotherapy without
irradiation in ve prospective trials.41 Skin ap recur-
rence is a frequent type of local recurrence after mas-
46 MASTECTOMY 479
tectomy42 and depends on ap thickness. In addition,
a proportion of breast tissue may be left behind in
attempts to preserve the IMF during mastectomy to
facilitate breast reconstruction. The IMF is a zone of
adherence of the supercial fascial system to the under-
lying chest wall43 and is anatomically dened as the area
where the skin of the lower pole of the glandular breast
tissue meets the chest wall. At this junction, the breast
parenchyma is bound down tightly to the deep fascia
of the thoracic wall. A proportion of breast tissue may
be left behind in attempts to preserve the IMF during
mastectomy to facilitate breast reconstruction.
Grade 2/3 complication
Repair
Postoperative radiation therapy or reexcision depend-
ing on anatomy.
Prevention
Skin ap recurrence might result from tumor emboli
implantation in the wound or small, unrecognized foci
in thick skin aps. Tumor emboli can escape from
blood vessels or lymphatics cut during the operation.
The thickness of the skin ap that is elevated is often
debated among surgeons. Tewari and associates42 took
biopsies of four quadrants under the skin aps of 37
patients with stages ranging from T1N1 to T4bN1.
They found residual breast tissue in 8 (21.6%), with
carcinoma cells in 3 of 8 patients (37.5%). Skin involve-
ment is also signicantly related to the site of the tumor,
clinical T staging, skin tethering, pathologic tumor
size, and perineural inammation as demonstrated by
Ho and coworkers44 in a detailed serial-section exami-
nation of 30 total mastectomy specimens.
Traditionally, the technique is to dissect the aps just
above the supercial layer of the supercial fascia of the
breast. In a study of ap thickness, Krohn and colleagues45
compared the survival and recurrence rates of women who
had ultrathin aps with patients with thicker aps during
mastectomy. The authors found similar 5- and 10-year
survival rates as well as recurrence rates. However, patients
with the ultrathin aps had increased incidences of wound
complications, length of hospital stay, and lymphedema.
More recently, Beer and associates46 found that the
supercial layer of the supercial fascia of the breast was
absent in 44% of the resected specimens. They noted that
when the supercial layer was present, there were islands
of breast tissue within the supercial layer in 42% of the
specimens. When present, the supercial layer had an
undulating appearance rather than a straight horizontal
interface. Furthermore, the distance between the super-
cial layer and the dermis varied within a single specimen
and across all specimens (from <5 mm in 82% to >10 mm
in 5.1%), as did the thickness of the supercial layer itself.
Thus, Beer and associates46 recommended looking for the
presence of the supercial layer, and if visible, it should
be used as a plane of dissection, provided that the skin
aps left behind appear viable.
 480 SECTION VI: BREAST SURGERY
B
Figure 464 The dotted line represents the boundaries of dissec-
tion during a mastectomy. A, The boundaries are the anterior border
of the latissimus dorsi laterally, the sternal border medially, the
inferior border of the clavicle superiorly, and the inframammary fold
(IMF) inferiorly. B, Also depicted is the technique of ap elevation.
At our institution, we aim to identify a plane of dissec-
tion that separates visible breast tissue from the region just
above the supercial layer. We have observed that this
plane of dissection varies between patients, depending on
body habitus, and leaves a ap thickness on average of 7
to 8 mm.
The IMF is another anatomic point of contention.
Although the lateral (anterior border of the latissimus
dorsi), medial (sternal border), and superior (inferior
border of the clavicle) borders of the breast are well dened,
the inferior border of the breast is less concrete (Fig. 464).
Carlson and colleagues47 examined 24 mastectomy speci-
mens obtained from 22 female breast cancer patients. They
removed the IMF specimens separately by elevating the
inferior skin aps over the anterior rectus sheath and
removing the underlying brofatty tissue off the rectus
sheath. After the tissue was xed, parafn-embedded, and
sectioned, the slides were screened for breast parenchyma
composed of either ductal or lobular elements. The authors
demonstrated a mean value of 0.02% breast tissue in the
Figure 465 The crinkly layer. The caudal extension of the
breast is approximately 2 to 3 cm below the IMF layer, as identied
by loose areolar tissue resembling tissue paper.
IMF after the total volume of the specimens was calculated
from the dimensions of the fresh tissue. All cases were
negative for carcinoma of the residual breast tissue.
In a study of 580 consecutive patients, Behranwala and
Gui48 identied only four tumors affecting the IMF (0.7%),
all of which were clinically palpable and proven malignant
on ne-needle aspiration cytology. They did not note any
incidental nding of breast cancer from additional speci-
mens during their series. Because the IMF may not be
fully included on conventional mammographic views, the
importance of good palpation of the IMF should be
routine during preoperative examination as well as intra-
operative assessment. At our institution, we dene the
caudal extension of the breast as approximately 2 to 3 cm
below the IMF identied by a layer of loose areolar tissue
resembling tissue paper that is referred to as the crinkly
layer (Fig. 465).
The preservation of the pectoral fascia is an additional
point for discussion. Dalberg and coworkers31 noted a
trend toward increased chest wall recurrences in patients
with preserved fascia, although the overall and event-
free survival did not differ. The total 5-year-cumulative
chest wall recurrence rate in patients with preserved fascia
was 12% compared with 7% in patients with removed
fascia, and the 5-year-local control rates were 86 and 91%,
respectively.
Wound Closure
Redundant Skin at the Lateral Edge of
the Mastectomy Scar
Consequence
Discomfort and poor cosmetic result. This skin can lie
at or above the bra line and can be distracting to
patients. It can interfere with wearing of an external
breast prosthesis and/or require surgical correction.49
Grade 1/3 complication
 46 MASTECTOMY 481

E
Figure 466 The technique for the creation of a sh-tail plasty as described by Hussein and coworkers. A, The elliptical incision of the
mastectomy scar. B, The wound after a mastectomy is completed. C, The upper and lower skin aps stitched at the anterior axillary line.
D, The redundant skin is advanced medially and stitched to the skin aps such that the dog ears can be excised. E, Fish-tail plasty after
wound closure. (AE, From Hussein M, Daltrey I, Dutta S, et al. Fish-tail plasty: a safe technique to improve cosmesis at the lateral end
of mastectomy scars. Breast 2004;13:206209.)

Repair 3 delayed) to prevent dog-ear deformity (Fig. 466).

Operative correction.
Prevention
Farrar and Fanning50 rst described the idea of Y-
shaped closure of the mastectomy wound in 1988, and
the term sh-shaped incision was introduced by Nowacki
and associates in 1991.51 Hussein and coworkers49 per-
formed 30 sh-tail plasties in 28 patients (27 primarily,
They achieved good cosmetic results in all 28 patients,
and none required surgical revision. Patients who were
older (>70 yr) and obese (BMI > 30) with large breasts
(mean weight of resected tissue 1015 g) needed to
undergo a sh-tail plasty in their study. This technique
did not prolong hospitalization.
Similarly, Gibbs and Kent52 described their technique
for creating a lateral V-Y advancement ap by retracting
 482 SECTION VI: BREAST SURGERY

E
Figure 467 Modied V-Y advancement technique for mastectomy closure. A, Standard incision for mastectomy. B, The lateral apex
is retracted for marking the superior and inferior aps. C, The superior and inferior aps are excised along the dotted line. D, The lateral
apex is retracted medially and secured to the superior and inferior skin edges. E, The closure as it appears after completion. (From Gibbs
ER, Kent RB 3rd. Modied V-Y advancement technique for mastectomy closure. J Am Coll Surg 1998;187:632633.)

the lateral apex medially and securing it to the approxi-
mated transverse incision about one third of the way
medial in the incision (Fig. 467). The incision is closed
with a newly created Y conguration. Other techniques
include extending the ellipse (by further lengthening of
the wound) and excising excess tissue. The scar may even-
tually extend around the back and further diminish the
cosmetic result.
Flap length discrepancy is a key factor in the creation
of dog ears. Gold53 described a technique similar to the
one we use at our institution whereby skin length of both
the superior and the inferior aps is measured with a silk
suture to avoid length asymmetry between both limbs of
the ellipse (Fig. 468). The technique was applied to over
250 patients and was especially effective in patients with
small breasts and relatively large tumors situated large
distances from the NAC.
Suture-Associated Issues
Consequence
Suture removal may provoke patient anxiety and result
in suture tracks. It also requires an additional follow-up
visit.
Grade 1 complication
Repair
Use of tissue adhesive as an alternative to sutures.
Prevention
Gennari and colleagues54 conducted a prospective, ran-
domized trial comparing skin closure with the tissue
adhesive 2-octylcyanoacrylate (OCA) with subcuticular
monolament suture and then blindly assessed cos-
metic and economic outcome at various time points.
They found that tissue adhesive skin closure was faster
 46 MASTECTOMY 483

B
A
A

Figure 468 Measurement with silk sutures for ap length.

A, Marking the long and short axes of the intended skin incision.
B, A snugly clamped suture to mark the superior skin incision.
C, A second suture placed to mark the inferior skin incision, leaving
the superior suture undisturbed. D, The intended ellipse is traced
with a skin marker. E, The wound after a cosmetic closure along the
F
long axis. F, Photographic depiction of the technique.
 484 SECTION VI: BREAST SURGERY
Lateral pectoral n.
Pectoralis major m.
Pectoralis minor m.
Medial pectoral n.
than the suture closure, the OCA patients developed
less tissue reaction, and the total cost in the OCA group
was signicantly lower (P < .001). The cost saving was
mostly due to reduced physician and ancillary services
and reduced equipment needs. However, there is a
learning curve in applying the OCA in that hemostasis
must be meticulous because the adhesive polymerizes
upon contact with blood and uid. If polymerization
occurs too rapidly, the adhesive can form an unsightly
plastic mass on top of the wound. In addition, subcu-
taneous sutures must be placed to minimize dead space,
maximize skin eversion, avoid depressed scarring, and
improve cosmetic outcome.
Lastly, the preference of staples over sutures for wound
closure in mastectomy is not directly addressed in the
literature in terms of cosmetic outcome or infectious com-
plications. At our institution, we use subcuticular sutures
to approximate the skin edges in mastectomy patients
because the psychological impact of staple removal and
the skin imprinting from the staples can be devastating to
the patient.
Postoperative Concerns
Postoperative Muscle Atrophy/Limitation of
Shoulder Movement
Consequence
Injury to the lateral pectoral nerve by accidental divi-
sion, cautery injury, or avulsion produces variable post-
operative atrophy, brosis, and shortening of the lower
third of the pectoralis major muscle (PMM). This limits
Figure 469 An artistic rendition of the anatomy
of the lateral and medial pectoral nerves as they
relate to the pectoralis minor muscle. The lateral
pectoral nerve courses along the undersurface of the
pectoralis minor muscle, and the medial pectoral
nerve courses through the pectoralis minor muscle
in 62% and exits around the lateral aspect of the
muscle in the remaining 38%.
shoulder motion and changes the cosmetic contour of
the pectoral region of the chest.
Grade 3 complication
Repair
Reconstruction with skin-muscle aps, as opposed to
breast implants or tissue expansion, to correct the infra-
clavicular depression followed with breast implants.
Prevention
Awareness of the anatomic distribution and course of
the medial and lateral pectoral nerves is essential to the
preservation of the PMM and its function. The upper
part of the PMM is innervated by the medial pectoral
nerve, whereas the lateral pectoral nerve supplies the
lower third of the muscle.55 The lateral pectoral nerve
courses along the undersurface of the PMM and may
be compromised during division and retraction of
removal of the pectoralis minor muscle (Fig. 469).
In 100 cadaver dissections, Moosman55 demonstrated
that the medial pectoral nerve coursed through the pec-
toralis minor muscle in 62% of the specimens, whereas it
exited around the lateral aspect of the muscle in the
remaining 38% (see Fig. 469). Hoffman and Elliot56 had
similar ndings and suggested that dissection between the
PMM and the pectoralis minor muscle is more likely to
result in disruption of a signicant portion of the innerva-
tion to the PMM. In addition, capsule formation around
breast implants has been implicated as causing compres-
sion of the medial and lateral pectoral nerves under the
PMM.

Phantom Breast Phenomena
Consequence
Psychological consequences as well as need for pain
management. Phantom breast syndrome (PBS) refers to
both painful and painless sensations of persistence of
the entire breast or parts of it despite its absence. Onset
may be immediately after mastectomy or more than 1
year after mastectomy58 and may persist for years. The
incidence of PBS is reported to vary from 17% to
64%.59,60
Grade 1 complication
Prevention
PBS sensation may be the nonpainful variety:
numbness, tension, twinging, pressuring, pounding,
itching, pricking, and bothering as described by
Rothemund and associates.61 The authors also addressed
the painful variant, which included sensations such
as twinging, tearing, tense, cutting, sharp, convulsive,
pressing, and cramplike. Whereas Rothemund and
associates61 found no relation of PBS to age, Staps
and coworkers62 reported that in their study of 89
women surveyed, those with PBS tended to be younger
(<55 yr) and premenopausal, they more often had
children and a preoperative history of breast
sensation.62
Kroner and colleagues63 performed a prospective
study of 120 women who underwent mastectomy in order
to investigate the clinical picture of PBS, its temporal
course, and the possible relationship between premas-
tectomy breast pain and PBS. They found that the
incidence of PBS was 25% initially and decreased to
about 12% at 1 year and that the location of the sensa-
tions changed from periareolar to the remainder of
the breast over time. Like Rothemund and associates,61
Kroner and colleagues63 did not note a relationship with
PBS and age, but they did nd a signicant relationship
between preoperative breast pain and PBS. The majority
of patients described their pain as knifelike, sticking,
shooting, or exteroceptive-like pain that could be
provoked or relieved by various environmental stimuli
such as emotional distress, exercise, or touch. The
attacks tended to be of high intensity but of very short
duration.
Other Complications
Pneumothorax
Pneumothorax is reported to have an incidence of approx-
imately 1% after MRM.64 This may be secondary to tech-
nique or preexisting medical conditions like asthma.
Treatment may include observation, chest tube insertion,
or even video-assisted thoracoscopic surgery with pleurode-
sis in the event of failure of resolution of the pneumotho-
rax with simple chest tube insertion.
Grade 1/2 complication
46 MASTECTOMY 485
Chylous Fistula
A chylous stula after an MRM is a rare occurrence.
However, major anatomic variations in the termination of
the thoracic duct may occur, rendering it susceptible to
injury.65 Nakajima and associates66 described four cases of
chylous stula after breast operations. In this paper, the
authors were able to treat all patients with conservative
management including cessation of oral intake and institu-
tion of intravenous nutrition for several weeks. However,
in the face of failure of nonoperative management, surgi-
cal ligation of the leaking thoracic duct or branch thereof
may be necessary. This complication is technically a func-
tion of the axillary dissection component of the MRM.
Grade 2/3 complication
Rare Complications
We surveyed multiple, highly regarded breast surgeons
in order to ascertain the incidence of more unusual com-
plications associated with mastectomies, given the paucity
of literature on this subject. Their experiences totaled
more than 3500 mastectomies over 20 years and included
1 deep venous thrombosis, 8 examples of ap necrosis
requiring operative intervention, 1 pneumothorax second-
ary to injection of local anesthetic, 5 instances of hemor-
rhage mandating blood transfusion, 6 postoperative
hematomas requiring reoperation, 4 wound infections
needing exploration in the operating room, 13 persistent
seromas necessitating operative intervention, 1 air embo-
lism, and 1 death secondary to sepsis originating from an
infected hematoma. None of the surgeons reported any
experiences with chylothorax, which has been suggested
in the literature but not documented.
Acknowledgments
We would like to thank Alison Estabrook, MD, Lorraine
Tafra, MD, Victor Zannis, MD, and Mel Silverstein, MD,
for contributing data from their vast experience.
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Section VII
SOFT TISSUE AND SKIN
Steven K. Libutti, MD
Experience is simply the name we give our mistakes.Oscar Wilde
47
Management of Soft Tissue Sarcoma
James C. Yang, MD
INTRODUCTION
The surgical approach to soft tissue sarcomas (STS) has
evolved extensively and, in some cases, paradoxically since
the mid 1980s. During the 1950s and 1960s, insufciently
aggressive surgery was considered the shortfall in the treat-
ment of primary sarcomas, but with improvements in diag-
nosis, imaging, and adjunctive therapies, this is no longer
the case. Although changes in technique and procedures
have occurred, these have not been nearly as dramatic as
those for sarcomas of bony origin. Therefore, the pitfalls
for the surgeon treating STS tend to be errors in judgment
rather than in technique. This chapter reviews the poten-
tial causes of suboptimal therapy at each stage of dealing
with STS, including imaging, biopsy, pathology, surgical
plann-ing, resection, and adjuvant therapies.
POTENTIAL PITFALLS IN MAKING
THE DIAGNOSIS
When a patient presents with a newly discovered soft
tissue mass, most often of the extremities, the rst decision
is what amount of investigation is warranted. Nearly all
soft tissue masses over 3 cm or with symptoms will require
a denitive investigation to determine their identity and
risk to the patient. Many smaller masses may also need
vigorous investigation unless a benign clinical diagnosis
can be made with assurance. If suspicion of malignancy
cannot be allayed, any invasive intervention must be
planned with the elements of a future denitive cancer
operation in mind. Such an operation must be able to
encompass any sites that were violated during a biopsy or
other manipulation of the mass. If the planning of a
denitive cancer operation is not clear from clinical exam-
ination, imaging of the mass and surrounding tissues
should precede a biopsy and help determine its placement.
If the approach to a resection is apparent, the biopsy and
all violated tissues should lie well within the margins of
that potential resection. The best chance of an adequate
resection is at the rst operation, and therefore, attention
to detail with respect to adequacy of resection and incor-
poration of any biopsy sites is critical to a successful
outcome. Both imaging and biopsy will be required for
all but small, simple, or supercial masses. These evalua-
tion modalities are examined individually.
POTENTIAL PITFALLS INVOLVING
PROPER STAGING
A potential pitfall in the work-up of a soft tissue mass is
in the misclassication of the lesion or in an inadequate
staging of the extent of the disease.
Prior to discussing management, a brief description of
STS is in order. Sarcomas in general are divided into
pediatric versus adult tumors and soft tissue versus bony
tumors. This is because there are signicant differences
in clinical behavior, prognosis, and treatment between
these entities. Pediatric small, round, blue cell tumors
 490 SECTION VII: SOFT TISSUE AND SKIN

(including alveolar and embryonal rhabdomyosarcomas, Table 471 Staging of Adult Soft Tissue Sarcomas
Ewings sarcoma, and primitive neuroectodermal tumors) Stage Primary Tumor Metastases*
often disseminate widely and require chemotherapy as the
mainstay of treatment. These can also occur in young Grade Size Depth
adults in whom they lead to diagnostic dilemmas and I Low Any Any No
mistreatment. Many of the pediatric tumors have been
found to have molecular markers that facilitate denitive II High 5 cm Any No
diagnosis,1 and these should be investigated if any doubts High >5 cm Supercial No
are raised that a tumor in a young adult is an atypical
III High >5 cm Deep No
presentation of a pediatric sarcoma, because treatment
may be radically altered. IV Any Any Any Yes
Conversely, for true adult sarcomas, surgery is the
*Nodal or distant.
primary treatment for localized as well as limited meta- From Fleming ID, Cooper JS, Henson DE, et al (eds): AJCC Cancer
static disease, and dissemination is often conned to the Staging Manual, 5th ed. Philadelphia: Lippincott-Raven, 1997.
lungs, where chemotherapy is of minimal benet. Osteo-
sarcomas and other bony tumors of young adults differ
from adult STS in diagnostic and surgical approaches, as 1.0

Probability of metastasis-free survival

Stage I
well as in the use of adjuvant chemotherapy, which is .9
effective in the former but not the latter. .8 Stage II
.7
An Approach to Proper Staging to .6
Avoid Misdiagnosis .5 Stage III

For true adult STS, there are hundreds of potential indi- .4

vidual tumor types, but the majority share similar thera-
peutic approaches as well as similar staging and prognosis.
Localized tumors are staged partially by histologic grade,
size (5 cm or >5 cm in diameter), and depth of involve-
ment (supercial or deep to fascia). Nodal involvement is
rarely a consideration in the presentation of STS (but is a
poor prognostic factor when present). The dominant
prognostic parameter is the histologic grade, based on
its microscopic appearance. An experienced pathologist
will use characteristics such as pleomorphism, cellularity,
mitotic rate, and necrosis to assign a grade to a tumor;
this drives the clinical staging system. The ability of dif-
ferent pathologists to do this accurately varies widely,2 and
here, the surgeon is at the mercy of the anatomic pathol-
ogist. The latest American Joint Committee on Cancer
(AJCC) staging system is presented in Table 471, and
the prognosis of these stages is shown in Figure 471.3
Thus, it is evident that misidentication and mistakes in
staging of STS can be some of the earliest and most det-
rimental pitfalls for those treating this disease, because
these errors will lead to mistreatment. Therefore, the
biopsy is critical to sarcoma management.
PROPER APPROACH TO
PREOPERATIVE BIOPSY TO AVOID
LOCAL RECURRENCE
For uncomplicated, supercial masses less than 3 cm,
simple excision is the indicated biopsy. This has the advan-
tages of complete histologic sampling and denitive treat-
ment if malignancy is not found. Major errors in this area
can occur if the lesion proves to be a sarcoma. The exci-
.3
.2
.1
0
0 12 24 36 48 60 72 84 96 108120132144156168180
Months from diagnosis
Figure 471 Metastasis-free survival by the American Joint Com-
mittee on Cancer (AJCC) stage (minimal differences from current
staging) for localized adult soft tissue sarcomas. Low-grade lesions
(stage I) have a very low risk of metastasis, even with prolonged
follow-up. (From Wunder JS, Healey JH, Davis AM, Brennan MF. A
comparison of staging systems for localized extremity soft tissue
sarcoma. Cancer 2000;88:27212730.)
sion scar should be longitudinal on the limb to facilitate
wide reexcision, and drains should be avoided if at all
possible or, when necessary, placed immediately adjacent
to the wound. Hemostasis is of the highest priority because
many sarcomas can be quite vascular, and hematoma can
carry malignant cells throughout tissue planes within a
limb, leading to an otherwise avoidable amputation. For
larger or more complex lesions, a diagnostic biopsy is
indicated. This can often be accomplished adequately by
core needle biopsy, depending on the experience of the
facility and pathologist. Some institutions advocate ne-
needle assessment, but in our hands, this is often inade-
quate for complete staging and occasionally incorrect
(owing to sampling error) when compared with the ulti-
mate resection specimen.4 A bruit, thrill, or pulsation
should alert one to the possibility of a vascular sarcoma
and the potential for major bleeding from a biopsy. Hema-
turia, abdominal mass, or associated bony destruction
should raise the possibility of a bony metastasis from renal
 47 MANAGEMENT OF SOFT TISSUE SARCOMA
cancer with a soft tissue component masquerading as a
sarcoma because these are particularly prone to hemor-
rhage after biopsy. Very large or xed lesions should have
imaging performed prior to biopsy to identify areas of
solid tumor versus liquefaction and to evaluate the struc-
tures that may need to be sacriced in future operations.
For instance, when an amputation is a possibility for a
large, deep, proximal thigh lesion, consideration should
be given to preserving the appropriate anterior or poste-
rior hemipelvectomy ap and not compromise it with a
biopsy site. Prebiopsy imaging suggesting bone or major
neurovascular involvement would particularly raise such a
concern. Conversely, if an unequivocal diagnosis of low-
grade (grade I) sarcoma is made from a biopsy, a lesser,
nonablative surgical option may be entertained. In such a
situation, the surgeon relies heavily on the pathologist to
accurately predict the biologic behavior of the tumor
based on histology. A relatively small number of experi-
enced sarcoma pathologists have seen sufcient cases and
have an adequate clinical database to assess and rene their
own reliability. For most experts, designating a sarcoma
as grade I indicates that there is less than a 10% chance
(and in most cases, 5% or less) that this lesion will ever
show metastatic behavior. Even large grade I lesions,
when correctly identied, are typically limb-threatening
rather than life-threatening malignancies, and the options
for local therapy are perhaps more exible. Although the
causal link between local recurrence and metastatic disease
has come under major scrutiny based on animal data as
well as prospective, randomized clinical studies, the
surgeon undoubtedly feels more comfortable considering
a function-sparing procedure with a higher risk of local
recurrence if he or she knows he or she is dealing with a
lesion with minimal metastatic potential. In a published
Figure 472 Computed tomography (CT) scan (left) and magnetic resonance imaging (MRI) (right) of a patient with low-grade liposarcoma
of the thigh. Lesion is indistinct on CT, but precisely delineated by MRI.
491
experience from our institution, none of 67 patients with
a diagnosis of low-grade (grade I) sarcoma of the extrem-
ities required an amputation at their initial presentation.5
The metastasis-related mortality in this group was only
4%, with a maximum follow-up extending beyond 10
years. Therefore, limb-sparing and function-sparing oper-
ations within this group of patients with low-grade sarco-
mas are the rule, and the major pitfall in their care is not
adequately considering these options. If the biopsy reveals
an unequivocal high-grade lesion, the appropriate deni-
tive procedure can be planned without further disturbing
tissue planes.
PROPER APPROACH TO
PREOPERATIVE IMAGING
Imaging of extremity sarcomas is also a point of some
controversy. Plain radiographs have little utility, and the
main competing modalities are computed tomography
(CT) scanning and magnetic resonance imaging (MRI).
Because the radiodensity and vascularity of some sarcomas
differ minimally from surrounding tissues, they can be
difcult to delineate on CT (Fig. 472). Conversely, the
effects that very large compressive masses can have on
surrounding tissue vis--vis inammation, edema, and
ischemia can exaggerate the apparent size of the malig-
nancy on MRI. This can lead to procuring excess margins
at a high functional cost. As an example, a patient with a
large high-grade sarcoma was evaluated by MRI (Fig.
473), and there appeared to be intimate contact between
the tumor and the femur over a signicant portion of its
circumference. Rather than plan an amputation, explora-
tion to evaluate local resection showed the periosteum to
 492 SECTION VII: SOFT TISSUE AND SKIN
Figure 473 MRI of high-grade sarcoma of the thigh shows what appears to be intimate contact with the femur over a large portion of
the femoral circumference. The signal of MRI may overestimate the extent of malignancy owing to edema or inammation in compressed
adjacent tissue. This patient had limb-sparing resection with a histologically negative periosteal margin.
be uninvolved, and a small periosteal stripping and local
resection achieved a satisfactory margin, which was then
followed by postoperative radiotherapy. Although she
subsequently developed aggressive metastatic disease and
expired, there was never any evidence of local recurrence.
This patient would have been disserved by an amputation
performed in anticipation of a positive margin based on
the MRI and demonstrates the potential for MRI to over-
estimate tumor extent.
In difcult cases, both CT and MRI may be needed to
preoperatively assess and anticipate the need for resection
of important structures. In rare cases in which bona de
bony involvement is the critical point, a nuclear medicine
bone scan can also be quite revealing. In general, the
burden of proof in this preoperative assessment and plann-
ing is on those who advocate resecting vital functional
structures; that approach is usually reserved for high-grade
or recurrent lesions in which imaging indicates substantial
direct involvement of the structure by surrounding,
unequivocally malignant tissue.
AVOIDING RECURRENCE AFTER
DEFINITIVE SURGICAL RESECTION
The major pitfall for the surgeon in the planning of
the denitive resection of an STS is to underestimate the
size of the lesion and the involved compartments. Local
recurrence can be a signicant problem, and therefore,
adequate planning and execution are critical. The approach
to surgical procedures for sarcoma has swung back and
forth over the last 50 years, and apparent contradictions
have been generated that are not completely resolved.
Prior to the work of Pack, Stout, and others, minimal
excisional procedures were often utilized and typically
failed to control local disease. Advocating more radical
resections, sarcoma surgeons of the 1950s and 1960s
pointed to improved local control and a consistent cure
rate in uncontrolled trials as evidence of the efcacy of this
approach. Then, the major success story from the 1970s
was the addition of radiation to lesser, limb-sparing sur-
geries to achieve comparable local control and survival
rates (again, with only one small randomized trial on
the subject).6,7 Finally, randomized, prospective trials of
limb-sparing surgery with and without adjuvant radiation
therapy supported the concepts that many lesions could
be treated with limb-sparing procedures without radiation
and that salvage of patients with local recurrence was
often possible without clearly impairing overall survival.8,9
At rst glance, this seems to effect the complete undoing
of 50 years of progress in the surgical management
of sarcomas. Yet other factors, also evolving over this
time interval, may offer a better interpretation. Earlier
diagnosis and improved recognition of sarcomatous lesions
with lower lethality have improved the overall prognosis
of sarcomas as a group. Improvements in surgical
imaging, planning, and technique have also allowed the
more satisfactory extirpation of these tumors without
violating tumors, encountering hemorrhage, or destroy-
ing function. In addition, when needed, radiation remains
a proven adjunct to surgery to improve local control
for difcult lesions, and improvements in technique have
 47 MANAGEMENT OF SOFT TISSUE SARCOMA
dramatically reduced the complications and morbidity of
this modality.
AVOIDING THE PITFALL OF
OVERAGGRESSIVE THERAPY AND
POOR FUNCTIONAL OUTCOME
In view of the developments previously discussed, current
pitfalls in surgical management of sarcomas are as likely
to be from overtreatment as from undertreatment or
technical misadventure. The surgeon should have a clear
grasp of the minimum of structures needed to retain a
productive extremity. Although largely outmoded by new
developments in prostheses, the original Tikoff-Lindberg
procedure as a substitution for forequarter amputation
was an early example of this concept. Neurovascular service
to the hand and forearm still maintained a productive
extremity even without shoulder joint integrity. Often,
the argument is made that major resections of muscle
groups will result in a poorly functioning limb with more
protracted rehabilitation than even an amputation. Yet, it
is often underappreciated that several major lower extrem-
ity muscle groups can be largely removed with only spe-
cic and minor decits. Loss of the lower extremity biceps
group has minimal impact in daily function and normal
ambulation. Loss of the quadriceps group causes most
difculty in ascending and descending stairs, but if even a
trace of knee extensor activity is preserved, this allows knee
hyperextension that supports weight-bearing in normal
ambulation with only a minor alteration in gait. Knee
bracing can often compensate for even total loss of quad-
riceps function when walking on level ground.
The concept that sarcomas do not have true capsules
and that the pseudocapsule often surrounding them
does not represent a safe excision plane, has been well
established. This envelope encompassing the obvious sar-
comatous mass does not represent a true brous capsule,
but is rather compressed reactive normal tissue, frequently
inltrated by malignant cells. Therefore, a truly negative-
margin surgical procedure remains outside of this transi-
tion zone. Conversely, surgeons often fail to realize that
a true brous or fascial structure adjacent to a sarcomatous
mass is often an adequate boundary if not invaded by
malignant cells. Thus, the fascia of a major muscle group
or the periosteal membrane, even when in direct apposi-
tion to the tumor, can represent an adequate margin if
not directly invaded. In those cases, there is no arbitrary
radial distance that denes the term wide (as in wide local
excision). This is important because most large extremity
sarcomas, high and low grade, will abut the fascia of a
muscle compartment, and performing multiple compart-
ment excisions or amputations is typically not necessary
to procure a sufcient margin at that interface. The deter-
mination of actual bony invasion on preoperative studies
can be problematic. Often, the limits of an STS are vague
on CT scanning because tumor and normal soft tissue
493
densities are similar. MRI can be more sensitive but will
detect inammation and edema as well as malignancy and
not discriminate well between these entities. As men-
tioned, we often use both modalities to estimate likely
surgical margins, realizing that the former can suffer from
false negatives whereas the latter can have false positives.
Without clear evidence of bony destruction, we will typi-
cally assume that the periosteal margin will be adequate
and conrm this at surgery by frozen sections. When
determining adequate margins intraoperatively, one must
proceed with a clear contingency plan in mind in the event
that bony involvement is encountered. This can be ortho-
pedic and prosthetic backup or amputation, and the initial
approach to the tumor must not compromise the backup
plan. The initial incision should respect the layout for
optimal closure of a possible amputation or allow a satis-
factory approach to a segmental or total bone resection
en bloc with the primary tumor mass. Often, one encoun-
ters the minimal positive margin, in which, for example,
tumor closely approaches a major nerve or vessel over a
very limited segment without frank involvement. If this
is the only point of compromise for an otherwise satisfac-
tory resection, a segmental resection of the neurovascular
structure versus a potential compromise of the resection
must be weighed. Segmental vascular resection results in
a more consistently satisfactory functional outcome than
that of nerve resection and grafting or repair. Ultimately,
the preservation of a poorly functional limb is not a desired
outcome, so careful marking of the point of compromise
(as well as the wider limits of the entire surgical eld) by
surgical clips and the administration of postoperative adju-
vant radiotherapy can be a realistic choice. A randomized
study showed that local recurrences of low-grade tumors
were reduced to very low frequency with adjuvant, post-
operative external beam radiotherapy (Fig. 474A).8 In
the case of low-grade tumors, one should select this option
without much reservation if the alternative is signicantly
morbid. Randomized studies also indicate that even high-
grade lesions can be well managed by this approach in
many circumstances. The signicant retrospective associa-
tion in many studies between local recurrence and meta-
static recurrence and death led many to conclude that
improved survival would result if one achieved better local
control. Yet, when this was subjected to randomized,
prospective studies testing local control measures, this
hypothesis was not substantiated. Two studies of post-
operative radiotherapy for high-grade tumors after
limb-sparing surgery (one by external beam and the other
using brachytherapy) demonstrated signicantly improved
local control with radiation, but neither documented an
improvement in overall survival8,9 (see Fig. 474B). In one
study, the local recurrences without radiotherapy were
either accompanied by prompt and aggressive metastatic
relapse (in which local recurrence was not a major com-
ponent of the clinical picture) or durably salvaged by re-
resection of the local recurrence, implying that the local
relapse was not seeding new metastatic sites after failure
 494 SECTION VII: SOFT TISSUE AND SKIN

100 Radiation
90
Percent without local recurrence

80
70 No radiation
60
50
40
30
P2.016
20
10
0
2 4 6 8 10 12
A Follow-up (years)

Radiation
100 100
90 90
Percent without local recurrence

No radiation
80 80 Radiation
70 70 No radiation

Percent survival
60 60
50 50
40 40
30 30
20 P2.71
20 P2.003
10 10
0 0
2 4 6 8 10 12 2 4 6 8 10 12
B Follow-up (years) Follow-up (years)
Figure 474 A, Randomized trial of adjuvant postoperative external beam radiotherapy versus no radiotherapy after limb-sparing resec-
tion of low-grade extremity sarcomas. Radiation signicantly reduced local recurrences in this malignancy. B, Randomized trial of adjuvant
postoperative external beam radiotherapy versus no radiotherapy after limb-sparing resection of high-grade extremity sarcomas. Local
recurrences were signicantly reduced with radiotherapy (left), but this had no demonstrable effect on overall survival (right). (A and B,
From Yang JC, Chang AE, Baker AR, et al. Randomized prospective study of the benet of adjuvant radiation therapy in the treatment of
soft tissue sarcomas of the extremity. J Clin Oncol 1998;16:197203.)

of the primary resection.8 Therefore, it is misguided to
apply a radical approach to resection when there are other
lesser options because of the concept that it is somehow
more curative. The strong retrospective association
between local recurrence and death10 is more plausibly due
to the aggressive intrinsic biology of some tumors, and
successfully reducing local recurrences does not affect
their tendency for distant metastases. This nding should
not be misconstrued as an excuse for poor or inadequate
surgery or neglect of the primary. Local recurrences can
severely affect quality of life, and the limited size of the
studies cited cannot exclude all possibility of an impact of
poorer local control on metastatic disease. Rather, these
studies indicate that after optimal limb-sparing surgery by
experienced sarcoma surgeons, the application of postop-
erative adjuvant radiotherapy can further reduce the
already low incidence of local recurrence. Yet those patients
who do not receive this adjuvant do not suffer a demon-
strably reduced overall survival. Both ndings (adjuvant
radiotherapy is locally effective, and local recurrences do
not clearly degrade overall survival) support the alternative
of relying on postoperative adjuvant radiotherapy in the
case of minimally compromised surgical margins in
which the surgical procedure necessary to rectify this com-
promise is morbid or defunctionalizing. A relatively
dramatic example of this is illustrated in Figure 475 in
which a patient with a very large low-grade sarcoma of the
quadriceps was explored and transfascial inltration into
the lateral portion of the biceps compartment was found.
Because hemipelvectomy was the only procedure that
could achieve widely negative margins and because the
lesion was of low grade, it was elected to resect the major-
ity of the quadriceps compartment and all gross disease in
the biceps compartment and apply postoperative radia-
tion. Care was taken to preserve the posterior thigh skin
in the event that hemipelvectomy was ultimately neces-
sary. With 6 years of follow-up, this patient has a func-
tional gait without prosthesis and is free of evident disease.
 47 MANAGEMENT OF SOFT TISSUE SARCOMA
Figure 475 A patient with very large low-grade liposarcoma of
the quadriceps compartment with transfacial extension to the pos-
terior compartment found at surgery. Rather than proceed to
amputation, a local resection of all gross disease was performed
followed by postoperative adjuvant radiotherapy. The patient has
useful function of the extremity, requires no assistance with ambu-
lation, and has shown no sign of recurrence for over 6 years. The
low metastatic risk of low-grade lesions supports the safety of such
a conservative surgical approach.
At this point, even if he suffers a local recurrence and
requires an amputation, he will have beneted from the
use of the functional limb for a substantial time and have
a survival expectation not signicantly affected by the
attempt at lesser surgery. Although such an approach is
not recommended for extensively inltrating high-grade
tumors, in this case, the main pitfalls in trying this strategy
for a low-grade tumor are poor follow-up that does not
detect the local recurrence until it is not amenable to
amputation or not technically preserving the amputation
as a salvage option during the rst procedure. The merit
of this approach seems evident when dealing with low-
grade lesions, and the two randomized trials cited earlier
indicate that it can also be entertained safely for many
high-grade tumors that are marginally resected. Gross
high-grade residual disease is not likely to be controlled
with this approach (and such patients were not included
in the randomized studies), but adjuvant radiotherapy,
careful follow-up, and a fall-back plan can be a safe option
for avoiding amputation after a marginal resection for
many of these tumors.
495
EARLY DETECTION, DIAGNOSIS, AND
TREATMENT OF RECURRENCES
If a recurrence occurs despite the best efforts of the surgi-
cal team to properly plan and execute a denitive surgical
resection, a salvage operation may be required.
Adult STS recur either locally or systemically. Although
retrospective studies indicate that local recurrences can be
harbingers of poor outcome, as noted previously, that
appears to be a reection of underlying aggressive biology
rather than a result of a cause and effect relationship.
Therefore, when a local recurrence appears in the absence
of disseminated disease, it should be treated vigorously,
and there would be some expectation that some of these
patients can yet be cured. If the patient has already been
treated with limb-sparing surgery and adjuvant radiother-
apy for a high-grade lesion, most surgeons will have to
proceed to an amputation as their salvage procedure. If
no adjuvant radiation therapy was given originally and the
recurrence is small or localized, a second limb-sparing
operation is possible in many patients. In almost all such
cases, this second procedure should be accompanied by
adjuvant radiotherapy because the primary has already
demonstrated its propensity for local recurrence. For low-
grade tumors, the option of amputation is reserved for
those patients with very large and inltrating recurrent
lesions that cannot be cleanly re-resected. Otherwise,
adjuvant external beam radiotherapy is also a useful com-
ponent of treatment after re-resection of these recurrences
if not already used.
The more difcult situation is when dissemination is
systemic and hematogenous. Fortunately, there is a marked
predilection for metastases to go exclusively to the lungs.
Here, a common pitfall is to not pursue pulmonary metas-
tasectomy adequately. In our experience, even the third
metastatic recurrence from sarcoma can be exclusively pul-
monary and still technically resectable.11 Because systemic
therapies such as chemotherapy are, at best, of brief benet
to a small minority of patients, surgery is the mainstay of
treatment for limited metastases conned to the lungs.
Although the success of pulmonary metastasectomy is
reduced with a higher number of lesions and a shorter
disease-free interval, there can still be extended periods of
tumor-free survival for some of these patients,1214 and the
real limitations are technical, related to pulmonary reserve
and resectability.
SUMMARY OF POTENTIAL PITFALLS
AND HOW TO AVOID THEM
Most often, mistakes in the management of primary adult
STS result from inadequate or inaccurate pathologic
grading and selection of suboptimal function-destroying
choices in surgery. Randomized studies have shown that
intrinsic biologic determinants are probably driving prog-
nosis more than are therapeutic options, implying that
 496 SECTION VII: SOFT TISSUE AND SKIN
draconian therapeutic options are less likely to improve
outcome than to impair quality of life. Yet, knowing when
a lesser, conservative resection is appropriate and safe is
still one of the most difcult clinical decisions. Isolated
local recurrences after limited surgery are often amenable
to curative surgical salvage procedures if one carefully
allows for such an exit strategy during planning for
the rst procedure. Lastly, aggressive pulmonary metasta-
sectomy represents the best and only route to cure or
prolonged disease-free survival once metastatic disease
occurs. The potential benets of such a resection should
be considered for each patient with metastatic disease
and should be rejected only when the clinical course or
technical considerations clearly predict rapid failure of this
strategy.
REFERENCES
1. Helman LJ, Meltzer P. Mechanisms of sarcoma develop-
ment. Nat Rev Cancer 2003;3:685694.
2. Alvegard TA, Berg NO. Histopathology peer review of
high-grade soft tissue sarcoma: the Scandinavian Sarcoma
Group experience. J Clin Oncol 1989;7:18451851.
3. Wunder JS, Healey JH, Davis AM, Brennan MF. A
comparison of staging systems for localized extremity soft
tissue sarcoma. Cancer 2000;88:27212730.
4. Barth RJ Jr, Merino MJ, Solomon D, et al. A prospective
study of the value of core needle biopsy and ne needle
aspiration in the diagnosis of soft tissue masses. Surgery
1992;112:536543.
5. Marcus SG, Merino MJ, Glatstein E, et al. Long-term
outcome in 87 patients with low-grade soft-tissue
sarcoma. Arch Surg 1993;128:13361343.
6. Rosenberg SA, Tepper J, Glatstein E, et al. The treatment
of soft-tissue sarcomas of the extremities: prospective
randomized evaluations of (1) limb-sparing surgery plus
radiation therapy compared with postoperative radiother-
apy in the treatment of soft tissue sarcomas in adults. Am
J Roentgenol 1975;123:123129.
8. Yang JC, Chang AE, Baker AR, et al. Randomized
prospective study of the benet of adjuvant radiation
therapy in the treatment of soft tissue sarcomas of the
extremity. J Clin Oncol 1998;16:197203.
9. Pisters PW, Harrison LB, Leung DH, et al. Long-term
results of a prospective randomized trial of adjuvant
brachytherapy in soft tissue sarcoma. J Clin Oncol 1996;
14:859868.
10. Pisters PW, Leung DH, Woodruff J, et al. Analysis of
prognostic factors in 1,041 patients with localized soft
tissue sarcomas of the extremities. J Clin Oncol 1996;14:
16791689.
11. Potter DA, Glenn J, Kinsella T, et al. Patterns of recur-
rence in patients with high-grade soft-tissue sarcomas.
J Clin Oncol 1985;3:353366.
12. Pogrebniak HW, Roth JA, Steinberg SM, et al. Reopera-
tive pulmonary resection in patients with metastatic soft
tissue sarcoma. Ann Thorac Surg 1991;52:197203.
13. Rizzoni WE, Pass HI, Wesley MN, et al. Resection of
recurrent pulmonary metastases in patients with soft-tissue
sarcomas. Arch Surg 1986;121:12481252.
14. Weiser MR, Downey RJ, Leung DH, Brennan MF.
Repeat resection of pulmonary metastases in patients with
soft tissue sarcoma. J Am Coll Surg 2000;191:184190.
48
Isolated Limb Perfusions and
Extremity Amputations
Joseph A. Blanseld, MD and
James F. Pingpank, Jr., MD
INTRODUCTION
In-transit metastatic disease in melanoma is dened as
recurrent melanoma within the intradermal or subcutane-
ous lymphatics that does not enter the nodal basins. In
the current American Joint Committee on Cancer (AJCC)
staging system, in-transit disease without metastatic lymph
nodes is considered stage IIIb and carries with it a 5-
year survival of 30% to 50%.1 For recurrent melanoma
conned to an extremity, simple excision can usually
eradicate the disease. Simple excision is sufcient and a
wide local excision is not necessary because it does not
improve recurrence rates. For larger numbers of lesions,
simple excision becomes technically prohibitive. For these
patients, isolated limb perfusion (ILP) is the treatment of
choice. ILP involves surgical isolation of an extremitys
circulation and placing that circulation into an extracor-
poreal circulation, which is separated from the systemic
circulation. After creating the new circuit, the isolated
limb is perfused with high doses of heated chemotherapy.
ILP should be contemplated in patients with intradermal
or subcutaneous in-transit melanoma metastases conned
to an extremity when there is no evidence of systemic
metastatic disease.
ILP was rst used to treat melanoma in the late 1950s
by Creech and coworkers.2 His group introduced the
practice of using an extracorporeal oxygenator to treat
melanoma conned to an extremity. Stehlin and associ-
ates3 modied the technique 20 years later to include
hyperthermia to enhance the cytotoxic effects of the che-
motherapy. Hyperthermia can enhance the cytotoxicity of
some chemotherapeutic agents and can cause selective
killing of neoplastic cells.3
Hyperthermic ILP with melphalan leads to an objective
response rate in 79% of patients, with a complete response
in 54%.4 Patients with a complete response have the best
prognosis. In patients with a complete response after per-
fusion, the 3-year survival is 60%, versus 35% in patients
not obtaining a complete response.4 Unfortunately, despite
the high objective response rates including a majority of
patients with complete remissions after ILP, there is a 22%
to 100% recurrence rate.5 Patients can be eligible for
repeat ILPs for recurrence.
Melphalan is the chemotherapeutic agent of choice for
ILP.6 Melphalan is an alkylating agent that is a derivative
of phenylalanine. Phenylalanine is a precursor in melanin
synthesis and is taken up preferentially by melanocytes,
making it an optimal choice for the treatment of
melanoma.7 Other agents, including cisplatin, interferon,
and tumor necrosis factoralpha (TNF-), have been
used in combination with or separately from melphalan,
but response rates and durations of response are not
signicantly higher than with melphalan alone.
The high tissue levels of chemotherapy obtained in the
bypass circuit can lead to some tissue toxicity. Also, if the
chemotherapy leaks into the systemic circulation, there
can be some systemic toxicity. Regional side effects include
skin, nerve, and muscle toxicity from the melphalan.
Systemic side effects include nausea and vomiting as well
as bone marrow suppression.
Isolated Limb
Perfusion in Melanoma
INDICATION
Patients with in-transit metastatic melanoma conned
entirely to an extremity whose melanoma is not ame-
nable to surgical excision
OPERATIVE STEPS
Step 1 Blood vessel dissection and collateral ligation
Step 2 Cannulation and attachment to pump
oxygenator
Step 3 Tourniquet application
Step 4 Reestablishment of circulation with ush
 498 SECTION VII: SOFT TISSUE AND SKIN
OPERATIVE PROCEDURE
Blood Vessel Dissection and Collateral Ligation
The rst step in ILP is to isolate inow and outow vessels
to the perfused extremity. ILP of the lower extremity is
most commonly performed through the external iliacs but
can also be performed via the femoral or popliteal vessels.
The location of vessel dissection depends on the distribu-
tion of the in-transit metastases as well as technical con-
siderations. These technical points include the patients
body habitus as well as history of previous lymph node
dissections or previous surgeries in the area. ILP in the
upper extremity is most commonly performed via the axil-
lary vessels; however, brachial vessels can also be used,
depending on the circumstances. In the lower extremity,
a more proximal perfusion does not improve the rate of
inguinal nodal recurrence. Thus, inguinal nodal recur-
rences are comparable for iliac and femoral vessels.8
The external iliac vessels are found via a retroperitoneal
approach. This approach is made in the lower abdominal
wall via a hockey-puck transplanttype incision. Both
the artery and the vein are circumferentially dissected dis-
tally, and all collaterals arising proximally or at the ingui-
nal ligament are ligated and divided.
Vascular Injuries as a Result of Dissection
See Section X, Chapter 60, Infrainguinal Revascularization.
Cannulation and Attachment to
the Pump Oxygenator
The external iliac vessels are cannulated and connected to
the inow and outow lines of an extracorporeal bypass
circuit. The perfusion circuit contains a heat exchanger,
an oxygenator, and a roller pump. The circuit is primed
using 700 ml of balanced salt solution, 1 unit of packed
red blood cells, and 1500 units of heparin. The typical
hematocrit in the circuit is 25%. One unit of blood is used
because regional toxicity cannot be further prevented by
providing a higher hematocrit.9 Flow rates of 300 to
500 ml/min for the lower extremity and 150 to 300 ml/
min in the upper extremity are optimal for the perfusion.
Flows are adjusted depending on line pressure and volume
of the reservoir or because of systemic leak.10 The circuit
is warmed using a heat exchanger, and the extremity is
covered in external warming blankets to maintain tissue
temperatures of 38.5C to 40C. Temperatures are
monitored by thermistor probes placed in the lower
extremity.
Dosing for melphalan is based either on body weight
or on actual limb volume. Older series used dosing regi-
mens based on body weight and ranged from 0.8 to
2.0 mg/kg for the lower extremity and 0.45 to 0.75 mg/
kg for the upper extremity. Wieberdink and coworkers11
modied the dosing regimen so that it was based on mea-
suring the actual volume of the limb. They then developed
Box 481 Wieberdink Grading System for
Regional Tissue Toxicity after ILP11
Grade I No subjective or objective evidence of reaction
Grade II Slight erythema and/or edema
Grade IIIConsiderable erythema and/or edema with some
blistering; slight disturbed mobility permissible
Grade IV Extensive epidermolysis and/or obvious damage
to the deep tissues, causing denite functional
disturbances; threatening or manifest
compartmental syndromes
Grade V Reaction that may necessitate amputation
a system to grade regional toxicity related to the perfu-
sion11 (Box 481). The volume of the extremity is deter-
mined by the volume of water it disperses when submerged
in a container of water, with an additional 10% added for
the lower extremity to estimate the volume of the lateral
thigh that is not submerged. Based on this regimen, an
optimal dose of melphalan was found that resulted in
reversible grade II or III toxicity in the majority of per-
fusions. In the lower extremity, this dose is 10 mg/L.
The upper extremity can tolerate a slightly higher dose
of 13 mg/L. These doses are currently used by most
centers.
Toxicities of Melphalan
Toxicities of melphalan are due to the direct effect of
melphalan in the perfusion circuit or to melphalan that
leaks into the systemic circulation. Regional side effects in
the eld of perfusion include effects on the skin, nerve,
and muscle.12 In one group of 425 patients after ILP, 85%
of patients had Wieberdink grade I or II toxicity, 15% had
grade II/IV toxicity, and 0.5% (2 patients out of 425)
had grade V toxicities.13
Consequence
Virtually all patients undergoing ILP have some evi-
dence of skin toxicity and dependent edema. Most of
these reactions are transient, and most patients recover
completely. Skin erythema typically starts 2 to 5 days
after the perfusion and reaches its maximal intensity at
about day 35. Over the subsequent 2 to 3 months, the
erythema fades to a bronze. Skin reaction can be more
severe including blistering or peeling of the skin, espe-
cially of the soles of the feet and the palms of the hands.
Dependent edema can also occur and may be a result
of the lymph node dissection that accompanies the
vessel isolation.
Peripheral neuropathy occurs in about half of the
patients undergoing ILP. Shooting pains down the treated
extremity typically occurs 2 to 3 weeks after a perfusion
and can last up to 3 months.14 A subset of patients has
longer-lasting neuropathy. Twenty percent of patients
after axillary perfusion and 2% of patients after iliac perfu-
sion have neuropathy that is considered long term (dened
as lasting >3 mo).15
 48 ISOLATED LIMB PERFUSIONS AND EXTREMITY AMPUTATIONS
Muscle effects tend to be the most troublesome long-
term effects after ILP.2,14 The clinical presentation of the
muscle injury can be extremely variable. Patients may have
little to no muscle effects with transient myalgias or may
have direct myotoxicity that leads to chronic pain and
atrophy.
Grade 1/2/3/4 complication, but typically grade
1/2 complication
Repair
Skin effects including erythema, blistering, and edema
can be managed by supportive care and applying silver
sulfadiazine (Silvadene) to blisters once they have
unroofed. Edema can be controlled with Jobst stock-
ings and is typically self-resolving. Neuropathy is also
self-resolving about 3 months after treatment but can
be treated with gabapentin for pain relief. Myotoxicity
occurs in a signicant form in up to 10% of patients
and is so far idiopathic. Fasciotomy does not improve
the direct effects of melphalan on muscle and should
be performed only with high compartmental pressures.
Regional toxicities must be carefully documented in
patients, especially myotoxic effects of the melphalan.
Patients who are reperfused tend to have enhanced
muscle toxicity with each subsequent perfusion.16
Prevention
Unfortunately, these complications of perfusion cannot
be prevented except by strictly compliance with dosing
regimens, as outlined previously.
Tourniquet Application
An Esmarch tourniquet is placed around the root of the
extremity to occlude any supercial veins that may allow
leakage of the chemotherapy into the systemic circulation.
Meticulous surgical ligation of all collaterals and tourni-
quet application to control supercial vessels avoids per-
fusate ow into the systemic circulation and also prevents
systemic blood from entering the perfusion circuit.
Systemic Leakage of Melphalan
Melphalan leak into the systemic circulation can cause a
variety of side effects including gastrointestinal upset and
bone marrow suppression. Nausea and vomiting occurs
within 24 hours of a perfusion if there is systemic absorp-
tion, and the bone marrow can be suppressed beginning
about 7 to 10 days after the perfusion.
Blood leakage into or out of the perfusion circuit
must be monitored during the course of the perfusion.
Reservoir volume is a key indicator for blood leakage
into or out of the circuit. An increase in the amount
of blood in the reservoir is indicative of a leak of blood
into the perfusion circuit from either the arterial or the
venous side. Increasing ow rates will increase the line
pressure, which can overcome arterial ow into the circuit.
By partially occluding the venous outow and thus
499
increasing the venous perfusion pressure, venous side
leakage into the circuit will stop. A decrease in the amount
of blood in the reservoir is indicative of a leak into the
systemic circulation. Flow rates can be decreased and/or
the tourniquet can be tightened to stop leakage into the
circulation.
Continuous intraoperative assessment of perfusate
leakage into the systemic circulation is an important
technique to discriminate small amounts of leakage. 131I-
radiolabeled albumin or 99Tc-labeled red blood cells is
allowed to circulate in the isolated circulation during the
procedure. A gamma counter is placed precordially to
provide continuous intraoperative monitoring of leak
during a perfusion.17 This system can discriminate a leak
of less than 1%.18 Systemic leak rates of less than 1% can
be achieved in the vast majority of patients (90%) using
the leak-monitoring systems.19
Consequence
The nausea and vomiting associated with melphalan is
self-limiting. Bone marrow suppression can lead to pos-
sible neutropenic fevers, thrombocytopenia and anemia,
and infectious complications. With intraoperative con-
tinuous assessment of leak detection, and consequently
low levels of systemic melphalan, most patients experi-
ence only transient nausea and vomiting for a day after
surgery and low levels of bone marrow suppression
approximately 7 to 10 days after treatment.
Grade 1 complication
Repair
Nausea and vomiting can be treated supportively
with antiemetics postoperatively. Bone marrow sup-
pression should be treated with neupogen if neutrope-
nia is present and with transfusions for anemia or
thrombocytopenia.
Reestablishment of Circulation
The perfusion circuit is disconnected after a 60-minute
perfusion, and residual drug is washed out of the tissues
with a 3-L ush of the extremity. This ushes any residual
drug from the vascular system to further lessen systemic
exposure to melphalan.
Extremity Amputations
In the era of ILP and immunotherapy to treat melanoma,
amputation is performed rarely to treat locoregionally
intractable extremity melanoma. Kapma and colleagues20
presented a series of 451 patients who underwent 501
ILPs over a 23-year period with only 11 patients (2.4%)
who needed to undergo an amputation for locoregionally
intractable melanoma. Amputation for melanoma confers
no increase in survival6,21 and should be performed only
for palliation.
 500 SECTION VII: SOFT TISSUE AND SKIN
REFERENCES
1. Balch CM, Buzaid AC, Soong SJ, et al. Final version of
the American Joint Committee on Cancer staging system
for cutaneous melanoma. J Clin Oncol 2001;19:3635
3648.
2. Creech O, Krementz ET, Ryan RF, Winblad JN. Chemo-
therapy of cancer: regional perfusion utilizing an extracor-
poreal circuit. Ann Surg 1958;148:616632.
3. Stehlin JS, Giovanella BC, de Ipolyi PD, et al. Results of
hyperthermic perfusion for melanoma of the extremities.
Surg Gynecol Obstet 1975;140:339348.
4. Klaase JM, Kroon BB, van Geel AN, et al. Prognostic
factors for tumor response and limb recurrence-free
interval in patients with advanced melanoma of the limbs
treated with regional isolated perfusion with melphalan.
Surgery 1994;115:3945.
5. Thompson JF, Hunt JA, Shannon KF, Kam PC.
Frequency and duration of remission after isolated limb
perfusion for melanoma. Arch Surg 1997;132:903907.
6. Fraker DL. Hyperthermic regional perfusion for mela-
noma and sarcoma of the limbs. Curr Probl Surg
1999;36:841907.
7. Luck JM. Action of p-dichloroethyl amino-L-phenylalanine
on Harding-Passey mouse melanoma. Science 1956;123:
984985.
8. Klaase JM, Kroon BB, van Geel AN, et al. The role of
regional isolated perfusion in the eradication of melanoma
micrometastases in the inguinal nodes: a comparison
between an iliac and femoral perfusion procedure.
Melanoma Res 1992;2:407410.
9. Klaase JM, Kroon BB, van Slooten GW, et al. Comparison
between the use of whole blood versus a diluted perfusate
in regional isolated perfusion by continuous monitoring of
transcutaneous oxygen study: a pilot study. J Invest Surg
1994;7:249258.
10. Alexander HR, Fraker DL, Bartlett DL. Isolated limb
perfusion for malignant melanoma. Semin Surg Oncol
1996;12:416428.
11. Wieberdink J, Benckhuysen C, Braat RP, et al. Dosimetry
in isolation perfusion of the limbs by assessment of
perfused tissue volume and grading of toxic tissue
reactions. Eur J Cancer Clin Oncol 1982;18:905910.
12. Olieman AF, Koops HS, Geertzen JH, et al. Functional
morbidity of hyperthermic isolated regional perfusion of
the extremities. Ann Surg Oncol 1994;3:382388.
13. Klaase JM, Kroon BB, van Geel BN, et al. Patient and
treatment related factors associated with acute regional
toxicity after isolated perfusion for melanoma of the
extremities. Am J Surg 1994;167:618620.
14. Bonifati DM, Ori C, Rossi CR, et al. Neuromuscular
damage after hyperthermic isolated limb perfusion in
patients with melanoma or sarcoma treated with chemo-
therapeutic agents. Cancer Chemother Pharmacol 2000;
46:517522.
15. Vrouenraets BC, Eggermont AM, Klaase JM, et al. Long-
term neuropathy after regional isolated perfusion with
melphalan for melanoma of the limbs. Eur J Surg Oncol
1994;20:681685.
16. Vrouentaets BC, Hart GA, Eggermont AM, et al.
Relation between limb toxicity and treatment outcomes
after isolated limb perfusion for recurrent melanoma.
JAMA 1999;188:522530.
17. Barker WC, Andrich MP, Alexandre HR, et al. Continu-
ous intraoperative external monitoring of perfusate leak
using I-131 human serum albumin during isolated
perfusion of the liver and limbs. Eur J Nucl Med 1995;
22:12421248.
18. Hoekstra HJ, Naujocks T, Schraffordt-Koops H, et al.
Continuous leaking monitoring during hyperthermic
isolated regional perfusion of the lower limb: techniques
and results. Reg Cancer Treat 1992;4:301304.
19. Klaase JM, Kroon BB, van Geel AN, et al. Systemic
leakage during isolated limb perfusion for melanoma. Br J
Surg 1993;80:11241126.
20. Kapma MR, Vrouenraets BC, Nieweg OE, et al. Major
amputation for intractable extremity melanoma after
failure of isolated limb perfusion. Eur J Surg Oncol
2005;31:9599.
21. Lienard D, Eggermont AM, Kroon BB. Thirty-ve years
of isolated limb perfusion for melanoma: indications and
results. Br J Surg 1996;83:13191328.
Section VIII
HERNIA
Stephen R. T. Evans, MD and
Leigh A. Neumayer, MD
Every great mistake has a halfway moment, a split second when it can be recalled
and perhaps remedied.Pearl S. Buck

49
Open Inguinal Hernia Repair with
Plug and Patch Technique
Derrick D. Cox, MD and Parag Bhanot, MD

INTRODUCTION INDICATIONS AND

Groin hernias, which can be further classied as inguinal
and femoral hernias, are among the most common condi-
tions for which patients undergo surgical intervention,
with approximately 800,000 cases performed annually.1
The lifetime risk of having a groin hernia repair is esti-
mated to be 14% for men and 2% for women.2 Elective
surgical repair is usually advised because of concerns
regarding incarceration and/or strangulation, particularly
with femoral hernias. A number of clinical studies have
proved elective surgical repair to be safe and effective with
a very low morbidity rate. This is in contrast to emergency
operations, which are associated with a substantial mor-
bidity and mortality; especially when concomitant bowel
resections are performed.3
A number of open repairs have been described and
classied depending on the type of dissection (anterior,
posterior) and the use of different mesh (Lichtenstein,
plug and patch, Prolene hernia system). The type of repair
performed is primarily based on the type of hernia as well
as the surgeons expertise. This chapter is dedicated to the
plug and patch technique; although much of the discus-
sion also applies to groin hernia repairs in general.
CONTRAINDICATIONS
The most common indications for groin hernia repair are
listed in Box 491. Repair of groin hernias in minimally
symptomatic individuals is still an area of debate. A ran-
domized clinical trial conducted by Fitzgibbons and
associates4 of 720 men concluded that this cohort can be
followed by delaying surgical intervention with minimal
morbidity. Femoral hernias represent a different clinical
entity with an increased incidence of complications and
emergent operations.5 Although there are few contraindi-
cations to groin hernia repair, a number of considerations
may delay repair (Box 492).
OPERATIVE STEPS
Although there is some variance in the technical aspects
of the plug and patch repair, the operation has well-
dened steps.
Step 1 Patient preparation
Step 2 Skin incision
 502 SECTION VIII: HERNIA

Box 491 Indications for Groin Hernia Repair
Symptomatic hernias
Prevention of progression of symptoms
Prevention of complications (incarceration, strangulation)
Treatment of complications (incarceration, strangulation)
Box 492 Contraindications to Groin Hernia
Repair
Uncontrollable ascites
Soft tissue infection
Pregnancy
Reversible causes of increased intra-abdominal pressure
(benign prostates hyperplasia [BPH], acute respiratory
issues)
Step 3 Dissection of subcutaneous layer and Scarpas
fascia
Step 4 Incision of external oblique fascia
Step 5 Mobilization of spermatic cord
Step 6 Identication and reduction of hernia (direct
and/or indirect)
Step 7 Mesh xation
Step 8 Anatomic closure of abdominal wall layers
OPERATIVE PROCEDURE
Dissection of the Subcutaneous Layer and
Scarpas Fascia
Hemorrhage
Consequence
Signicant postoperative bleeding would be very
unusual from this dissection. However, ecchymosis
or supercial hematoma may result from improper
ligation of smaller venous branches.
Grade 1 complication
Repair
Hematomas of signicant size may need to be evacu-
ated to prevent subsequent soft tissue infection. Other-
wise, conservative measures may be employed.
Prevention
Preoperatively, patients should be instructed to avoid
antiplatelet and other anticoagulation medications. A
number of small veins encountered in the subcutaneous
layer can simply be cauterized. One or two prominent
supercial epigastric veins are also located in the inci-
sion near the pubic tubercle, and these must be suture-
ligated to prevent bleeding.
Incision of the External Oblique Fascia
Ilioinguinal Nerve Injury
The ilioinguinal nerve is solely a sensory nerve with a
distribution of the upper and medial aspects of the thigh
and scrotum. It is located overlying the spermatic cord
directly underneath the external oblique fascia and is at
risk for transection at this stage.
Consequence
Inadvertent transaction of the ilioinguinal nerve will
result in sensory deprivation in the associated derma-
tomes described. Inability to recognize that the nerve
has been transected may also lead to a neuroma and
chronic inguinal pain.
Grade 1/2 complication
Prevention
An understanding of the anatomy of the nerve is crucial
to recognizing its usual course through the eld of
dissection. Care should be taken when incising the
external oblique fascia to ensure that the nerve has been
separated from its underside. This can be accomplished
by rst partially transecting the fascia in the direction
of the supercial ring and then lifting up on the medial
and lateral leaets to further expose the inguinal canal
(Fig. 491).
Mobilization of the Spermatic Cord
Ischemic Orchitis/Testicular Injury
Consequence
Ischemic orchitis is the result of venous congestion
within the testicle secondary to venous thrombosis
within the spermatic cord. This process may lead to
testicular atrophy. The reported incidence is less
than 1%.6
Grade 3/4 complication
Repair
The management of orchitis includes observation and
use of nonsteroidal anti-inammatory medications for
several weeks. A duplex ultrasound should be per-
formed to assess perfusion of the testicle. Ischemia
and/or infarction may warrant orchiectomy.
Prevention
This injury can be prevented by limiting dissection
within the spermatic cord. This requires precise identi-
cation of the indirect hernia sac to safely mobilize it
from the medial aspect of the cord (Fig. 492). In
patients in whom the hernia sac is large and adherent,
the distal portion of the sac can be left in situ with a
high ligation proximally.
Hemorrhage
Consequence
Mobilization of the spermatic cord usually requires
division of the cremasteric muscle bers overlying the
hernia sac. Improper recognition of bleeding from the
transected muscle bers may result in hematomas.
Grade 1/2 complication
 49 OPEN INGUINAL HERNIA REPAIR WITH PLUG
A
B
Figure 491 A, The external oblique fascia has been transected
into medial and lateral leaets. The ilioinguinal nerve is just visible
overlying the spermatic cord (tip of the forceps). B, The ilioinguinal
nerve has been carefully dissected along its course from the inter-
nal ring to the pubic tubercle without the use of cautery or exces-
sive retraction.
Repair
Hematomas of signicant size may need to be evacu-
ated to prevent subsequent soft tissue infection. Other-
wise, conservative measures may be employed.
Prevention
Division of the cremasteric muscle is necessary to fully
mobilize the hernia sac from the spermatic cord.
Cautery is usually sufcient to prevent bleeding from
the muscle bers, but it must be done before retraction
occurs.
Mesh Fixation
Mesh Infection and/or Exposure
Consequence
Mesh infection accounts for over 40% of all adverse
events, as reported by the U.S. Food and Drug Admin-
503
Figure 492 The Penrose drain encircles both the indirect hernia
sac and the spermatic cord. The testicular vessels (tip of the hemo-
stat) are directly adjacent to the hernia sac and can be easily
injured.
istration.7 An increased risk is associated with incarcer-
ated and femoral hernias. The sequela of an infection
is dependent upon the source of infection, the degree
of infection, and the type of mesh placed for the repair.
Exposed mesh is considered to be contaminated and is
included in the same algorithm.
Grade 3/4/5 complication
Repair
The majority of plug and patch meshes are constructed
from polypropylene. This type of mesh can resist bacte-
rial colonization and has the ability to incorporate into
native tissue. This accounts for a higher likelihood of
being able to salvage the mesh with long-term antibi-
otic administration and/or drainage of any associated
abscess. However, if the source of infection is an enteric
stula, mesh removal is required. In the presence of
sepsis, aggressive measures are instituted with immedi-
ate operative exploration and systemic antibiotics.
Prevention
The most important preventive measure is to maintain
strict sterile technique throughout the operation. The
surgical team has to be vigilant in not compromising
the surgical eld or contaminating the mesh before its
placement. Preoperatively, any remote sources of infec-
tion, such as pneumonia, urinary tract infection, or soft
tissue infections, should be addressed before the oper-
ation. Although there has been some debate in the
literature on the use of intravenous antibiotics for
hernia cases, the authors believe that this is an impor-
tant measure coinciding with the conclusions from
several randomized studies.811 Lastly, despite the lack
of level-one evidence, the authors believe that the use
of adhesive surgical barriers that serve as physical bar-
riers against bacterial migration between the skin and
the mesh is important.
 504 SECTION VIII: HERNIA
Enterocutaneous Fistula
Consequence
The reported incidence of enterocutaneous stulas is
less than 1% in large series and is described as isolated
case reports.12 Consequences include mesh infection,
intra-abdominal abscess, sepsis, and mortality.
Grade 3/4/5 complication
Repair
The management of intestinal stulas should follow
surgical principles in terms of patient resuscitation and
sepsis control. Eventually, the treatment also needs to
take into account the associated mesh infection. The
operation will include exploratory laparotomy, excision
of mesh, repair of stula, and closure of the abdominal
wall without mesh.
Prevention
Prolene mesh is known to be associated with signicant
adhesion formation that may lead to mesh erosion into
the bowel and resultant stula.13,14
The principal concept in prevention is to avoid direct
opposition of the mesh with bowel. This is particularly
relevant with the plug placement because a signicant
portion is placed into the preperitoneal space for direct
hernias and adjacent to the hernia sac in indirect hernias.
If the hernia sac has been opened, a secure high ligation
must be performed.
Hernia Recurrence
Consequence
The lifetime recurrence rate is less than 5% in most
large series.15,16 Multiple risk factors include morbid
obesity, diabetes, connective tissue disorders, smoking,
ascites, and previous hernia repair. Patients will present
with symptoms similar to their initial complaints of the
presence of a bulge, new onset of inguinal pain, and
incarceration with possible strangulation. It is impor-
tant to note that most failures are secondary to techni-
cal causes and can be prevented. The major complication
of a recurrent hernia repair is the increased recurrence
rate of approximately 20%.17 Hematomas, seromas, tes-
ticular atrophy, and chronic pain all have an increased
incidence as well.
Grade 3/4 complication
Repair
With symptomatic recurrences in surgical candidates,
a repeat attempt at a hernia repair is warranted. Many
large series, including the randomized clinical trial by
Neumayer and associates,18 have demonstrated superior
results with a laparoscopic approach to the repair of a
recurrent hernia. This approach has the advantage of
avoiding scar tissue and altered anatomy caused by the
previous repair. However, depending on the surgeons
expertise, an open approach may be used with place-
ment of an additional plug and patch.
Figure 493 Although the onlay portion of the mesh has been
secured to the edges of the inguinal canal, the repair is compro-
mised secondary to improper reconstruction of the internal ring.
Prevention
There are several important technical considerations to
ensure the lowest rate of failure. As previously listed,
there are individual considerations of each patient that
may warrant delaying the operation. The identication
of all concomitant hernias (direct and indirect compo-
nents) is critical. A recurrence through the internal ring
can occur if the indirect hernia sac is not properly
dissected and reduced prior to placement of the
plug component or if the onlay mesh is excessively
loose around the proximal spermatic cord (Fig. 493).
A direct hernia recurs if the onlay portion does not
adequately reinforce the inferomedial portion of the
inguinal oor.
Vas Deferens Obstruction
Consequence
Vasal obstruction related to inguinal herniorrhaphy is
an uncommon complication, but it is recognized as
a cause of azoospermia in the male infertility patient
with an incidence of 0.3%.19 The obstruction is due to
a foreign body reaction to the mesh with resultant
decreased vasal luminal diameter.
Grade 2/3 complication
Repair
Vasogram is the gold standard to diagnose the injury.
In addition to the presence of mesh, vasal obstruction
can also result from direct iatrogenic injury caused by
ligation or cauterization, vascular compromise, or
extrinsic compression. Most of these injuries may be
identied intraoperatively and a primary repair may be
attempted, maintaining fertility. Microsurgical repair of
an injury to the vas deferens has excellent outcomes
with a patency rate of 65% at follow-up.20 Vasal obstruc-
tion secondary to a desmoplastic reaction to the mesh
will ultimately require reexploration of the groin.
 49 OPEN INGUINAL HERNIA REPAIR WITH PLUG 505

Prevention
The use of mesh results in a desmoplastic reaction, and
thus, it is important to avoid placement of the plug
component in direct contact with the vas deferens.
The spermatic cord should be handled carefully during
dissection of the hernia sac to reduce the risk of exposing
a bare vas deferens to the mesh. Also, the patch placed for
reinforcement of the transversalis fascia should have a slit
large enough to allow safe passage of the spermatic cord
through the deep ring.

Nerve Entrapment/Chronic Inguinal Pain

Consequence
The literature is equivocal with regard to elective divi-
sion of the ilioinguinal nerve to reduce the risk of an A
inadvertent injury and consequent chronic pain. A ran-
domized, controlled trial by Picchio and coworkers21
concluded that the occurrence of postoperative pain is
unaffected by elective division of the ilioinguinal nerve.
Moreover, the purposeful transection of the ilioingui-
nal nerve was related to sensory disturbances in the
corresponding dermatome.
Grade 2/3 complication
Repair
Chronic pain secondary to nerve entrapment can be
frustrating to manage. Outpatient management includes
injection of local anesthetic combined with steroids in
the location of the nerve and/or point of tenderness.
If this is not effective, exploration of the groin is war-
ranted. However, identication of the affected nerve B
may be difcult secondary to scar tissue. If the nerve
Figure 494 A, The plug component has been properly secured
can be located, it should be freed from the scar tissue at the level of the internal ring orice. However, the ilioinguinal
with possible reimplantation. Neurectomy of either the nerve is clearly in contact with the mesh, predisposing to nerve
ilioinguinal, the iliohypogastric, and/or the genito- entrapment and chronic pain. B, The onlay component used to
femoral nerves may ameliorate the neuralgia.22 reinforce the transversalis fascia has entrapped the ilioinguinal nerve
with one of the permanent sutures.
Prevention
Meticulous attention must be paid to identifying all
nerves and branches in the surgical eld, especially the
ilioinguinal nerve. When obtaining exposure and repair-
ing the hernia, care should be taken not to damage the Repair
nerves by entrapment with staples, sutures, or pros- Management of the vascular injury depends on the
thetic materials (Fig. 494). One should avoid exces- severity of the complication and the vessel involved.
sive retraction on the nerve. Cautery should be kept Patients with acute venous injury presenting with deep
away from the nerve to prevent electrical injury. venous thrombosis should be appropriately anticoagu-
lated. If there is severe compromise of venous outow
Femoral Vessel Injury
from the lower extremity, an angiogram may be needed
Consequence to determine the extent of the thrombosis and possible
Injury of the femoral vein as a result of unobserved intervention. Reoperation may be needed to remove
constriction by suture placement can manifest with the offending suture(s).
subsequent thromboembolic complications. Femoral Intraoperative arterial injury can be repaired primarily
artery injury may cause vascular compromise depending with adequate exposure. Most suture needle injuries can
on the presence of collateral arterial ow. In addition, be controlled with direct pressure without placement of
delayed complications include aneurysms and arterio- additional sutures. Long-term sequela such as aneurysms
venous stulas. and arteriovenous stulas has to be evaluated with addi-
Grade 3/4 complication tional studies before repair is attempted.
 506 SECTION VIII: HERNIA
Cord
Ext. oblique
Pouparts lig.
Coopers lig.
Femoral v.
Ant. femoral fascia
Figure 495 The external iliac vessels become the femoral
vessels as they transverse underneath the inguinal ligament. These
vessels can be injured during dissection of the inguinal oor
or during placement of sutures into the shelving edge of the
ligament.
Prevention
The surgeon has to be aware of the anatomy of the
underlying femoral vessels when placing sutures for
xation of the mesh (Fig. 495). This is important
specically during repair of femoral hernias in which
the femoral vein is situated lateral to the hernia sac.
Compression of the femoral vein is a well-reported
complication of the McVay repair.23 For inguinal
hernias, the lateral border of the mesh should be
secured to the shelving edge of the inguinal ligament,
which will avoid the anterior wall of the vein. Injury to
the femoral artery can occur during reconstruction of
the inguinal oor near the deep inguinal ring, at which
point the artery is situated just posterior to the trans-
versalis fascia. Lastly, any signicant bleeding must be
controlled with appropriate exposure and direct
visualization.
Anatomic Closure of Incision
Seroma
Consequence
A postoperative seroma will develop in 1.2% of patients.6
Most seromas are usually asymptomatic and resolve
without any intervention (Fig. 496).
Grade 1/2 complication
Repair
The management of a symptomatic or infected seroma
follows a different algorithm. Seromas that are persis-
tent can be aspirated if large and symptomatic. This
must be done under sterile conditions, and the risk of
contamination of the wound and underlying mesh has
Figure 496 Computed tomography (CT) scan obtained in the
early postoperative period to evaluate for a recurrence demon-
strates a moderate-size seroma in an asymptomatic patient. This
seroma resolved after 2 months without any intervention.
to be considered. Infected seromas may be a sequela of
a deeper infection. As with any abscess and soft tissue
infection, the wound may have to be opened and
explored formally to ensure a potential bowel injury
does not exist.
Prevention
Careful dissection of the appropriate tissue planes will
help to prevent seromas. Excessive subcutaneous tissue
should be suture-ligated to control lympathics.
Other Complications
Bowel Obstruction
Small or large bowel obstruction may occur during reduc-
tion of the indirect hernia sac.24,25 If a high ligation is
performed before placement of the plug component, it is
important to assess whether there is bowel within the sac
and to completely reduce it before ligation is completed
to avoid trapping the bowel. Conservative measures may
be employed, but there should be a low threshold for
exploration.
Grade 2/3 complication
Mesh Migration
The plug component may migrate from its desired loca-
tion at the orice of the internal ring and be found entirely
in the preperitoneal space, intraperitoneal, or the scrotum
(Fig. 497). Depending on the location of the migrated
mesh and resulting sequela, it may have to be removed.
This complication can be avoided by proper anchoring of
the plug of the mesh to the inguinal oor.
Grade 3/4 complication
 49 OPEN INGUINAL HERNIA REPAIR WITH PLUG
Figure 497 Laparoscopic view of the intraperitoneal migration
of the plug component. The external iliac vessels are adhered to
the mesh, which precluded its safe removal. In addition, the poten-
tial for a bowel injury exists because the sigmoid colon is in close
proximity.
Ileovaginal Fistula
This complication has been cited as case reports in the
literature after repair of a strangulated femoral hernia.26
Care should be taken to ensure adequate reduction of all
herniated contents to avoid the risk of perforation second-
ary to suture placement. The presence of a stula should
raise the concern for infected mesh, and the algorithm
previously described should be followed.
Grade 3/4 complication
Paravesical Abscess
This rare complication has been reported in a case series
of six patients by Imamoglu and colleagues.27 These indi-
viduals underwent operations for treatment of paravesical
abscess related to previous inguinal hernia repairs. The
injury was determined to be caused by sutures that had
been placed into or adjacent to the urinary bladder. Fixa-
tion sutures for the mesh must be appropriately placed.
Grade 3/4 complication
REFERENCES
1. Rutkow IM. Demographics and socioeconomic aspects of
hernia repair in the United States in 2003. Surg Clin
North Am 2003;83:10451051.
2. Ruhl CE, Everhart JE. Risk factors for inguinal hernia
among adults in the United States population. Am J
Epidemiol 2007;167:11541161.
3. Nilsson H, Stylianidis G, Haapamaki M, et al. Mortality
after groin hernia surgery. Ann Surg 2007;245:656660.
4. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al.
Watchful waiting versus repair of inguinal hernia in
minimally symptomatic men: a randomized clinical trial.
JAMA 2006;295:285292.
507
5. Alimoglu O, Kaya B, Okan I, et al. Femoral hernia:
a review of 83 cases. Hernia 2006;10:7073.
6. Bittner R, Auerland S, Schmedt CG. Comparison of
endoscopic techniques versus Shouldice and other open
nonmesh techniques for inguinal hernia repair: a meta-
analysis of randomized controlled trials. Surg Endosc
2005;19:605615.
7. Robinson TN, Clarke JH, Schoen J, et al. Major mesh-
related complications following hernia repair: events
reported to the Food and Drug Administration. Surg
Endosc 2005;19:15561560.
8. Rios A, Rodriguez JM, Munitiz V, et al. Antibiotic
prophylaxis in incisional hernia repair using prosthesis.
Hernia 2001;5:148152.
9. Yerdel MA, Akin EB, Dolalan S, et al. Effect of single-
dose prophylactic ampicillin and sulbactam on wound
infection after tension-free inguinal hernia repair with
polypropylene mesh: the randomized, double-blind,
prospective trial. Ann Surg 2001;233:2633.
10. Aufenacker TJ, van Geldere D, van Mesdag T, et al. The
role of antibiotic prophylaxis in prevention of wound
infection after Lichenstein open mesh repair of primary
inguinal hernia: a multicenter double-blind randomized
controlled trial. Ann Surg 2004;240:955960.
11. Perez AR, Roxas MF, Hilvano SS. A randomized, double-
blind, placebo-controlled trial to determine effectiveness
of antibiotic prophylaxis for tension-free mesh herniorrha-
phy. J Am Coll Surg 2005;200:393397.
12. Losanoff JE, Rochman BW, Jones JW. Enterocutaneous
stula: a late consequence of polypropylene mesh abdomi-
nal wall repair: a case report and review of literature.
Hernia 2002;6:144147.
13. Harrell AG, Novitsky YW, Peindle RD, et al. Prospective
evaluation of adhesion formation and shrinkage of intra-
abdominal prosthetics in a rabbit model. Am Surg 2006;
72:808813.
14. Mahmouduslu HY, Erkek AB, Cakmak A, et al. Incisional
hernia treatment with polypropylene graft: results of
10 years. Hernia 2006;10:380384.
15. Bringman S, Ramel S, Heikknen TJ, et al. Tension-free
inguinal hernia repair: TEP versus mesh-plug versus
Lichtenstein: a prospective randomized controlled trial.
Ann Surg 2003;237:142147.
16. Frey DM, Wildisen A, Hamel CT, et al. Randomized
controlled trial of Lichtensteins operation versus mesh-
plug for inguinal hernia repair. Br J Surg 2007;94:3641.
17. Eklund A, Rudberg C, Leijonmarck CE, et al. Recurrent
inguinal hernia: randomized multicenter trial comparing
laparoscopic and Lichenstein repair. Surg Endosc 2007;
21:634640.
18. Neumayer L, Giobbie-Hurder A, Jonasson G, et al. Open
mesh versus laparoscopic repair of inguinal hernia. N Engl
J Med 2004;350:18191827.
19. Shin D, Lipshultz LI, Golstein M, et al. Herniorrhaphy
with polypropylene mesh causing inguinal vasal obstruc-
tion: a preventable cause of obstructive azoospermia.
Ann Surg 2005;241:553558.
20. Sheynkin YR, Hendin BN, Schlegel PN, et al. Micro-
surgical repair of iatrogenic injury to the vas deferens.
J Urol 1998;159:139141.
21. Picchio M, Palimento D, Attanasio U, et al. Randomized
controlled trial of preservation or elective division of
 508 SECTION VIII: HERNIA
ilioinguinal nerve on open inguinal hernia repair with
polypropylene mesh. Arch Surg 2004;139:755758.
22. Aleri S, Rotondi F, DiGiorgio A, et al. Inuence of
preservation versus division of ilioinguinal, iliohypogastric,
and genital nerves during open mesh herniorrhaphy:
prospective multicenter study of chronic pain. Ann Surg
2006;243:553558.
23. Normington EY, Franklin DP, Brotman SI. Constriction
of the femoral vein after McVay inguinal hernia repair.
Surgery 1992;111:343347.
24. Ferrone R, Scarone PC, Natalini G. Late complication of
open inguinal hernia repair: small bowel obstruction
caused by intraperitoneal mesh migration. Hernia
2003;7:161162.
25. Chuback JA, Singh RS, Sills C, et al. Small bowel
obstruction resulting from mesh plug migration after open
inguinal hernia repair. Surgery 2000;127:475476.
26. Deshpande PV. Ileovaginal stula: A complication
following repair of a strangulated femoral hernia. Br J Clin
Pract 1964;18:744745.
27. Imamoglu M, Cay A, Sarihan H, et al. Paravesical abscess
as an unusual late complication of inguinal hernia repair in
children. J Urol 2004;171:12681270.
50
Prolene Hernia System
Hernia Repair
Edward W. Nelson, MD
INTRODUCTION
The ideal method to accomplish the successful and durable
repair of groin hernias remains a topic of ongoing debate;
centuries after these defects were rst described by early
anatomists and more than 100 years after the rst reported
surgical cures by Marcy (1881), Bassini (1887), and
Halsted (1889). Today, entire surgical texts and journals
are devoted to the history, evolution, and ongoing prog-
ress in surgery for hernia repair.1,2 The most current lit-
erature describing the relative merits of the open versus
the laparoscopic approach is a prime example of both the
science and the emotion still generated by this common
yet difcult problem.3
Ideally, repair of groin hernias should be safe, reliable,
and easy to learn and, above all, have a low recurrence
rate. Champions exist for a variety of currently popular
repairs, but today, most surgeons performing open repairs
have adopted the concept, rst introduced by Usher and
colleagues in 1960,4 of using mesh as part of the repair.
Current literature comparing these various mesh repairs is
limited by nonrandomization, short follow-up, and oper-
ative variability.57 Today, the Lichtenstein tension-free
mesh repair, the plug and patch repair reported by Robbins
and Rutkow, the preperitoneal Kugel repair, and the
Prolene hernia system (PHS) are the most common ante-
rior tension-free mesh repairs performed, all with excellent
overall results and minimal recurrence rates when per-
formed by experienced surgeons.812
Groin hernia repair using the PHS was rst reported by
Gilbert and associates in 1999,11 and numerous follow-up
reports continue to document the ease of use and low
recurrence rate of this system when compared with other
methods.1315 Unique to this system is the intent to have
a mesh repair designed to cover the entire myopectineal
orice.16 With this intent, potential defects at the internal
ring, inguinal oor, and femoral canal are covered with
both onlay and underlay patches held together by a con-
nector inserted into the hernia defect16 (Fig. 501). When
the PHS repair is completed, the onlay patch covers the
entire oor of the inguinal canal as in the Lichtenstein
repair, the underlay patch covers and supports the preperi-
toneal space as in a Kugel or laparoscopic approach, and
the connector plugs the defect without the risk of
migration seen with the two-piece plug patch repair17
(Fig. 502). Using this repair in over 11,000 procedures,
recurrence rates of 0.014% have been reported.13 A sys-
tematic series of steps have been well described in the
correct use of the PHS to minimize the risk of pitfalls in
its use in the repair of groin hernias.
INDICATIONS
Inguinal hernia repair
Direct hernia repair
Indirect hernia repair
OPERATIVE STEPS
Step 1 Exposure of inguinal oor
Step 2 Conrm type of hernia present
Step 3 Development of external pocket for onlay
patch
Step 4 Prepare posterior space for underlay patch
Step 5 Deployment of underlay patch
Step 6 Secure onlay component
OPERATIVE PROCEDURE
Exposure of the Inguinal Floor
Like all open inguinal hernia repairs, the PHS repair
requires a standard inguinal incision, opening in the sub-
cutaneous fat, Scarpas fascia, and the external oblique
fascia in the direction of its bers to the external ring.
Assuming a correctly placed incision, the complications
that can occur during exposure of the inguinal oor and
mobilization of the spermatic cord include excessive
bleeding and hematoma formation in the subcutaneous
space, incorrect placement of the external oblique fascial
opening, and injury to the ilioinguinal nerve or spermatic
cord.
 510 SECTION VIII: HERNIA
Figure 501 A stem connector inserted through the hernia
defect holds together the onlay and the underlay mesh patches.
(B)
(A)
Figure 502 The underlay patch (A) supports the preperitoneal
space and is connected to the onlay patch (B) covering the oor
of the inguinal canal.
Consequence
Excessive bleeding in the subcutaneous space can result
in hematoma formation and increased risk of secondary
infection.
Making the opening in the external oblique fascia either
too high or too low can compromise exposure of the cord,
risk injury to the iliohypogastric nerve as it penetrates the
abdominal musculature, and make closure of the fascia
over the onlay patch more difcult. Careless technique in
opening the external oblique fascia and mobilization of
the cord can result in injury to the ilioinguinal nerve with
resultant postoperative numbness in its area of sensation,
or injury to the spermatic cord or its contents resulting in
cord hematoma, vas deferens injury, or compromise of
testicular circulation with secondary pain, swelling, and
possible atrophy.
Prevention
Subcutaneous vessels, when encountered, require
careful attention to hemostasis with either electrocau-
tery or absorbable ties, if necessary. The external oblique
fascial opening should be oriented on clear identica-
tion of the external ring. A carefully placed incision in
the direction of the fascial bers with clear identica-
tion of the nerve and cord prior to completion of the
opening is mandatory. For the PHS repair, the ilioin-
guinal nerve need not be elevated off the cord, thereby
minimizing traction and potential injury.
Conrm the Type of Hernia Present
Once the cord is mobilized, the oor of the inguinal canal
can be inspected for the presence of a direct hernia. If a
direct hernia is found, the possibility of an indirect hernia
must also be perused by opening the external spermatic
fascia at the anterior medial aspect of the cord near the
internal ring. If the preoperative examination suggested a
femoral hernia, Coopers ligament must be exposed to
allow inspection for a femoral defect.
Consequence
Unless the cord is inspected for an indirect sac, the
potential for recurrence at the internal ring will be
greatly increased.
Prevention
Methodical and consistent inspection for both direct
and indirect defects is mandatory in all hernia repairs.
Development of the External Pocket for
the Onlay Patch
The space between the external oblique fascia and the
internal oblique muscle must be opened to allow place-
ment of the onlay patch. This dissection includes clearing
the attachments from the shelving edge of the inguinal
ligament and opening the space lateral to the internal ring
to the upper third of the ligament (Fig. 503).
Consequence
Injury to the iliohypogastric nerve during the superior
part of the dissection can occur, and several perforating
vessels may also be disrupted. Most importantly, if
the lateral and superior spaces are not opened com-
pletely enough, the onlay mesh will not lie at in order
to conform to the abdominal wall. Especially in thin
patients, onlay mesh that is not at may be palpable or
cause discomfort.
Prevention
The space for the onlay mesh must be developed with
attention to creating a space large enough to cover not
only the oor of the inguinal canal but also the superior
and lateral areas beyond the area normally covered by
other open mesh repairs. When done under direct
 50 PROLENE HERNIA SYSTEMHERNIA REPAIR
Figure 503 The fascial plane beneath the external oblique fascia
is dissected to create a space for the onlay patch.
vision and with adequate care, the space can be opened
without nerve or vessel injury. If necessary, the onlay
mesh can be trimmed slightly in smaller patients to
appropriately cover the area needed.
Prepare the Posterior Space for
the Underlay Patch
The preperitoneal space, between the abdominal wall and
the preperitoneal fat, is developed to allow space for the
underlay patch. For indirect inguinal hernias, this is done
through the internal ring; for direct hernias, it is created
through the posterior oor defect. At the internal ring,
this requires taking down all bers remaining between the
cord and the hernia sac; for direct hernias, any remaining
attenuated bers of the inguinal oor must be opened to
fully expose the direct sac. For both indirect and direct
defects, the sac is not opened or ligated but rather inverted
back into the abdominal cavity. In either case, the space
is carefully created using nger dissection to sweep cir-
cumferentially to actualize the preperitoneal space
(Fig. 504). A moist 4 4 gauze sponge can be used to
facilitate this dissection and hold the space open. To be
complete, the preperitoneal space should extend to
Coopers ligament inferiorly and well back, beyond the
defect in all other directions.
Consequence
Failure to completely actualize the preperitoneal space
will not permit the underlay patch to atten out against
the underside of the abdominal wall to cover the entire
myopectineal orice. Opening or tearing the perito-
511
Figure 504 The preperitoneal space is dissected through the
hernia orice to allow space for the underlay patch.
neum will result in the underlay mesh laying directly
on the abdominal viscera.
Prevention
The space for the underlay mesh must be carefully and
completely developed. Although mesh trimming may
be needed, it should be minimized. Any inadvertent
holes in the peritoneum should be closed with running
absorbable suture to prevent direct contact between
the mesh and the abdominal viscera.
Deployment of the Underlay Patch
The onlay patch is folded and grasped with a clamp or
sponge forceps with the long axis parallel to the ingui-
nal ligament. The entire underlay patch is inserted into
the previously developed preperitoneal space, and with
the onlay patch held above the defect, the underlay
patch is spread out away from the connector using a
nger or forceps (Fig. 505). Increased intra-abdominal
pressure, when the patient later stands or strains, will
enhance deployment by attening the underlay mesh
against the inside of the abdominal wall. If the defect
is considerably larger than the connector, interrupted
sutures should be placed to snug up the tissue around
the connector.
Consequence
Failure to atten the underlay mesh as much as possible
will result in failure to adequately cover all areas where
recurrent hernias may occur: the femoral canal, inguinal
oor, and internal ring. Unless the underlay patch is
 512 SECTION VIII: HERNIA
Figure 505 The underlay patch is inserted and spread out in
the preperitoneal space whereas the onlay patch is held above with
the long axis parallel to the inguinal ligament.
deployed as completely as possible, the repair will be
compromised and the risk of recurrence increased. If
the defect is considerably larger than the connector,
added risk of recurrence next to the connector or extru-
sion of the underlay mesh is possible.
Prevention
Correct deployment of the underlay patch begins
with the careful creation of the preperitoneal space as
described earlier in the section on Development of the
External Pocket for the Onlay Patch. Once in place,
the underlay mesh must be carefully and patiently
spread out, to be as at as possible. If the defect is much
larger than the connector, the tissues around the con-
nector should be approximated to ensure a snug t.
Secure the Onlay Component
Once the underlay patch is completely deployed, the onlay
component is attened and positioned in the previously
created space between the external oblique fascia and the
oor of the inguinal canal. The lateral ap is positioned
rst and the mesh trimmed to allow a at t, held in place
with sutures at the pubic tubercle, transverse arc, and
inguinal ligament. A slit is made to accommodate the cord
and sutures placed between the mesh and the shelving
edge of the inguinal ligament on either side of the cord.
Fixation sutures should be placed at least inch from the
edge of the mesh and the mesh fashioned to lie as at as
possible (Fig. 506).
Figure 506 The onlay patch should lie at against the inguinal
oor and under the external oblique fascia with anchoring sutures
on either side of the cord and at the pubic tubercle.
Consequence
Failure to adequately open the pocket between the
external oblique fascia and the abdominal wall as
described earlier in the section on Conrm the Type
of Hernia Present, can cause folding or wrinkling of
the onlay mesh. Placing more sutures than needed will
increase the risk of postoperative pain, especially when
placed too deeply at the pubic tubercle. Sutures placed
too tightly around the spermatic cord can result in
compromise of cord circulation, with testicular swell-
ing, pain, and atrophy. Sutures placed too close to the
mesh edge can pull through.
Prevention
The PHS is a groin hernia repair requiring few sutures
to secure the mesh, and the temptation to place more
sutures than necessary must be resisted. A minimal
number of stitches to attach the mesh to the tubercle,
around the cord, and if needed, to the anterior abdom-
inal wall should be used.
SUMMARY
When appropriately applied, groin hernia repair using the
PHS has a competitively low recurrence rate with minimal
and largely preventable complications. To maximize the
advantages of both an onlay and an underlay mesh system,
special attention in creation of the space below the exter-
nal oblique fascia and in the preperitoneum is required.
 50 PROLENE HERNIA SYSTEMHERNIA REPAIR
REFERENCES
1. Condon RE, Nyhus LM. Hernia, 4th ed. Philadelphia: JB
Lippincott, 1995.
2. Lichtenstein IL. Hernia Repair Without Disability, 2nd
ed. St. Louis: Ishiyaku Euroamerica, 1987.
3. Neumayer L, Giobbie-Hurder A, Jonasson O, et al, and
the Veterans Affairs Cooperative Studies Program 456
Investigators. Open mesh verses laparoscopic mesh repair
of inguinal hernia. N Engl J Med 2004;350:18191827.
4. Usher FC, Cogan JE, Lowery TI. A new technique for
the repair of inguinal and incisional hernias. Arch Surg
1960;81:847854.
5. Nienhuijs SW, van Oort I, Keemers-Gels ME, et al.
Randomized trial comparing the Prolene Hernia System,
mesh plug repair and Lichtenstein method for open
inguinal hernia repair. Br J Surg 2005;92:3338.
6. Mayagoitia JC. Inguinal hernioplasty with the Prolene
hernia system. Hernia 2004;8:6466.
7. Huang CS, Huang CC, Lien HH. Prolene hernia system
compared with mesh plug technique: a prospective study
of short- to mid-term outcomes in primary groin hernia
repair. Hernia 2005;9:167171.
8. Lichtenstein IL, Shulman AG. Ambulatory outpatient
hernia surgery. Including a new concept, introducing the
tension-free repair. Int Surg 1986;71:17.
9. Robbins AW, Rutkow IM. The mesh-plug hernioplasty.
Surg Clin North Am 1993;73:501512.
513
10. Kugel RD. The Kugel repair for inguinal hernias. In
Bendavid R, Abrahamson J, Arregui ME, et al (eds):
Abdominal Wall Hernias: Principles and Management.
New York, Berlin: Springer-Verlag, 2001; pp 504507.
11. Gilbert AI, Graham MF, Voigt WJ. A bilayer patch device
for inguinal hernia repair. Hernia 1999;3:161166.
12. Amid PK, Lichtenstein IL. Long-term result and current
status of the Lichtenstein open tension-free hernioplasty.
Hernia 1998;2:8994.
13. Gilbert AI, Young J, Graham MF, et al. Combined
anterior and posterior inguinal hernia repair: intermediate
recurrence rates with three groups of surgeons. Hernia
2004;8:203207.
14. Kingsnorth A, Wright D, Porter C, Robertson G. Prolene
hernia system compared with Lichtenstein patch: a
randomised double-blind study of short-term and
medium-term outcomes in primary inguinal hernia repair.
Hernia 2002;6:113119.
15. Murphy JW. Use of the Prolene hernia system for inguinal
hernia repair: retrospective, comparative time analysis
versus other inguinal repair systems. Am Surg 2001;67:
919923.
16. Fagan SP, Awad SS. Abdominal wall anatomy: the key
to a successful inguinal hernia repair. Am J Surg
2004;188(6A suppl):3S8S.
17. LeBlanc KA. Complications associated with the plug-and-
patch method of inguinal herniorrhaphy. Hernia 2001;5:
135138.
51
Laparoscopic Inguinal
Hernia Repair
Benjamin Kim, MD and Quan-Yang Duh, MD
INTRODUCTION
Laparoscopic inguinal hernia repair has evolved to become
a safe and effective alternative for inguinal herniorrhaphy.
The rst report of a laparoscopic approach was in 1990
by Ger and associates1 in which indirect inguinal hernias
were repaired by a transabdominal laparoscopic staple
closure of a patent processus vaginalis. Following this
study, other reports were published including a trans-
abdominal rolled mesh plug technique2 and an intraperi-
toneal onlay mesh technique.3 These methods were
eventually abandoned owing to high recurrence rates.
Over time, the laparoscopic approach built upon the idea
of applying a prosthetic to the posterior wall of the groin
developed by Nyhus, Stoppa, and Wantz.4 The hallmarks
of this approach included complete dissection of the groin
in the preperitoneal space, identication of all myopectin-
eal orices, and placement of mesh over the entire ingui-
nal-femoral region (Fig. 511). This has now become the
laparoscopic procedure of choice.
Several reports have demonstrated the efcacy of the
laparoscopic approach to inguinal hernia repairs. Liem and
coworkers5 compared laparoscopic versus conventional
anterior hernia repair and found that the laparoscopic
group had faster postoperative recovery and a recurrence
rate similar to that of the open group. A study by
Andersson and colleagues6 found that laparoscopic totally
extraperitoneal hernia repair resulted in less postoperative
pain, shorter time to recovery, earlier return to work, and
no difference in overall complications when compared
with open tension-free repair. The results from the
Veterans Administration (VA) Cooperative Study showed
that, although laparoscopic repair of inguinal hernias
resulted in less pain and earlier return to normal activity,
recurrence was signicantly more common after laparo-
scopic repair.7 However, this study also reported similar
recurrence rates between laparoscopic and open inguinal
hernia repairs when surgeons with a large volume of expe-
rience performed the laparoscopic procedures. This nding
underscores the challenge in learning this approach and
the need for technical mastery in order to achieve consis-
tently satisfactory results.8
The laparoscopic approach to inguinal hernia repair can
be divided into two types: the transabdominal preperito-
neal approach (TAPP) and the totally extraperitoneal
approach (TEP). Initially, most procedures were per-
formed with the TAPP approach for exposure of the
posterior oor of the groin because the groin anatomy
was easier to delineate. However, the TEP approach avoids
violation of the peritoneal cavity, potentially reducing
some of the complications associated with the TAPP
technique. Although understanding the inguinal anatomy
from an extraperitoneal posterior view can be difcult,
hernia surgeons have become more comfortable with this
exposure and can achieve similarly low recurrence rates
using this technique.4 By and large, the TEP approach
can be applied to most clinical circumstances in which
laparoscopic inguinal hernia repair is performed, and it is
described here.
INDICATIONS
Recurrent inguinal hernias
Bilateral inguinal hernias
Patients who are able to tolerate general anesthesia
Patients who are eager to return to normal activity
earlier
RELATIVE CONTRAINDICATIONS
Prior or planned extraperitoneal operations (e.g., radical
prostatectomy)
Previous pelvic irradiation
Extremes of age
Contraindications to laparoscopy (e.g., severe chronic
obstructive pulmonary disease)
OPERATIVE STEPS
Step 1 Positioning and trocar insertion
Step 2 Dissection of preperitoneal space
 516 SECTION VIII: HERNIA

Inf

Vas

Sper

X
x x

Figure 512 Port placement.

Figure 511 Posterior view of potential right groin myopectineal
defects. D, direct hernia defect; F, femoral hernia defect; I, indirect
hernia defect; Inf, inferior epigastric vessels; Sper, spermatic vessels;
Vas, vas deferens.

Step 3 Exposure of pubic bone and
ligament
Step 4 Dissection of direct hernia
Step 5 Dissection of indirect hernia
Step 6 Placement of mesh
Step 7 Trocar removal
OPERATIVE PROCEDURE
Positioning
The monitor is placed at the foot of the operating bed
with the surgeon standing by the patients shoulder on
the opposite side of the hernia. If bilateral inguinal hernias
are present, the surgeon starts opposite the side of the
larger, more symptomatic hernia. Both of the patients
arms are tucked to the side, and the patient is placed in
the Trendelenburg position once the dissecting ports are
inserted. The patient needs to be paralyzed to allow for
insufation of the preperitoneal space.
Trocar Insertion
Trocar insertion should be controlled and under direct
vision to avoid serious complications. A standard three-
trocar technique is used: a 10-mm port subumbilically, a
Coopers 5-mm port in the right lower quadrant, and a 5-mm port
in the left lower quadrant (Fig. 512). All ports are placed
within the preperitoneal space. Complications of trocar
insertion are discussed in Section I, Chapter 7, Laparo-
scopic Surgery.
The rst trocar placed is the 10-mm subumbilical port,
using an open technique. This port is placed slightly off
of the midline to stay in the space behind the rectus
muscle and in front of the posterior rectus sheath. If it is
placed in the midline, where the anterior and posterior
rectus sheaths merge, it will enter the peritoneal cavity.
Following this port placement, a 10-mm, 30 angled lap-
aroscope is inserted and used to bluntly dissect the areolar
tissue in the preperitoneal space, using a gentle sweeping
motion. The preperitoneal space is cleared out laterally
toward the anterior superior iliac spine to provide enough
space for placement of the other ports. Alternatively, a
balloon dissector can be used instead of manual dissection,
although it is more expensive.
The temptation here is to take down the areolar tissue
and move toward the symphysis pubis rather than toward
the anterior superior iliac spine. However, by making a
conscious effort to move the dissection laterally, enough
space can be created to place the other ports, after which
the remaining areolar tissue can be dissected in a more
precise fashion, using laparoscopic graspers.
 51 LAPAROSCOPIC INGUINAL HERNIA REPAIR 517

Left Right

Coop
Pubic
Bladder

Dir

Figure 513 Midline view of preperitoneal space. Left, left A

Coopers ligament; Right, right Coopers ligament.

Exposure of the Pubic Bone and

Coopers Ligament
This step is done at the outset of the procedure in order Coop
to clearly dene the midline. Coopers ligaments are found
just lateral and slightly cephalad to the pubic bone (Fig.
513). Coopers ligament is where the mesh will be
anchored medially. Small veins overlie the pubic bone, and
they can be injured during exposure.

Injury during Exposure

Consequence
Bleeding can occur if these small veins are injured by
excessive manipulation of the pubic bone, thereby
obscuring the view of Coopers ligaments.
Grade 1 complication
Repair
The bleeding will typically stop on its own.
Prevention
Identify the symphysis pubis and then, by gently
probing, conrm the position of the pubic bone. There
is no need for excessive rubbing.
Injury to the Bladder
Consequence
Injury to the bladder can occur during exposure of the
pubic bone, given that this structure lies in close
proximity to it and Coopers ligaments.
Grade 2 complication
Repair
Bladder injuries can be repaired laparoscopically by
suture closure. This is followed by suprapubic or Foley
catheter drainage of the bladder. Urology consultation
is often necessary.
Prevention
Emptying the bladder immediately preoperatively can
reduce its size. Once the size of the bladder is reduced,
Dir
B
Figure 514 A, Right direct hernia defect with contents reduced.
Coop, Coopers ligament; Dir, direct hernia defect. B, Correspond-
ing pictorial view.
avoid it and dissect the pubic bone under direct
vision.
Dissection of Direct Hernia
Identication of a Direct Hernia
As Coopers ligament is exposed, a direct hernia, if present,
will generally be reduced (Fig. 514). If it is not, gentle
traction on the peritoneal attachments should provide
enough force to reduce the sac. Occasionally, in chronic
direct hernias, a pseudosac may be present. The pseu-
dosac is a posterior invagination of the transversalis fascia
and should be distinguished from the direct hernia sac,
which is continuous with the peritoneum (Fig. 515).
Consequence
If not recognized, the pseudosac can be vigorously dis-
sected, leading to confusion in identifying the groin
anatomy and potential injury to the peritoneum or the
iliac vein. The peritoneal tear can then result in entry
 518 SECTION VIII: HERNIA
Coop
Inf
Psd
A separates the direct and indirect inguinal hernia defects.
Coop
Inf
Psd
B tion and repair are usually required.
Figure 515 A, Right-sided pseudosac is being dissected free
from the direct hernia defect. Coop, Coopers ligament; Inf, inferior
epigastric vessels; Psd, pseudosac. B, Corresponding pictorial view.
of air into the peritoneal space, obscuring the view of
the anatomy.
Grade 1 complication
Repair
Tears of the peritoneum can be repaired using an
endoloop, clips, or suture. In general, peritoneal tears
can be closed after the hernia is repaired.
Prevention
Recognizing the pseudosac can prevent confusion
regarding the anatomy and avoid unnecessary dissec-
tion of this structure. The pseudosac needs to be dis-
sected away from the true sac and left along the anterior
abdominal wall, allowing the true sac and peritoneum
to fall back toward the abdominal cavity. Gently pulling
the peritoneum posteriorly while providing counter-
traction on the pseudosac anteriorly will peel the true
hernia sac off.
Injury to the Inferior Epigastric Vessels
Consequence
Bleeding from this injury can obscure the view of the
groin anatomy. Unrecognized and untreated blood
loss can potentially result in transfusions and lead to
postoperative hematomas.
Grade 2 complication
Repair
If the inferior epigastric artery or vein is injured, it is
best controlled with endoclips.
Prevention
It is critical to identify the inferior epigastric vessels to
prevent injury. It is a key landmark of the groin, and it
These vessels are identied behind the rectus muscles
and are best left adhered to them during dissection of
the preperitoneal space. Dissecting the inferior epigas-
tric vessels off the rectus muscles will cause more bleed-
ing during the procedure and makes placement of the
mesh difcult.
Dissection of Indirect Hernia
Injury to the External Iliac Vessels
Consequence
Injury to the external iliac artery or vein causes severe
bleeding and, potentially, a CO2 embolus.
Grade 3/4 complication
Repair
Laparoscopic repair is very difcult, and open explora-
Prevention
The external iliac vessels are located just below the area
anked medially by the vas deferens and laterally by the
spermatic vessels. Dissecting within this area risks injury
to the external iliac vessels. They can usually be identi-
ed by their pulsation and are best avoided by identify-
ing the peritoneal edge of the hernia sac and gently
pulling it away from the preperitoneal tissue under
direct vision.
Identication of an Indirect Hernia
The indirect hernia sac is found along the spermatic cord
and just cephalad to it. Within the spermatic cord, the vas
deferens and the spermatic vessels are located medial and
lateral, respectively, merging through the internal ring.
Together with the inferior epigastric vessels, the vas
deferens and the spermatic vessels form the so-called
Mercedes-Benz sign (Fig. 516). Cord lipomas, if
identied, are usually found laterally along the spermatic
vessels.
Usually, the indirect hernia sac is reduced from the
internal ring by gentle traction and dissection (Fig. 517).
If the sac is too long or too large, it can be dissected
 51 LAPAROSCOPIC INGUINAL HERNIA REPAIR 519

Inf

Inf
Coop

Ind

Vas
A

Sper
Inf

Coop

Figure 516 Mercedes-Benz sign. The inferior epigastric

vessels (Inf), the vas deferens (Vas), and the spermatic vessels (Sper)
represent the three spokes seen in the Mercedes-Benz symbol.

at the internal ring and divided. The proximal part of
the sac, which is continuous with the peritoneum, is dis-
sected off of the cord structures and ligated with an
endoloop. The distal end of the transected sac should be
left open and not ligated. Ligating the distal sac will cause
a hydrocele.
Consequence
During dissection of the cord structures, the indirect
hernia sac can be torn, creating a pneumoperitoneum.
Sometimes, the sac is intentionally transected, also cre-
ating a pneumoperitoneum. This can hinder the view
of the anatomy in the preperitoneal space.
Grade 1 complication
Repair
Tears in the peritoneum are best repaired with
endoloops. Clips or sutures can also be used for closure.
If not repaired, loops of bowel can herniate through
the defect, creating a preperitoneal hernia.
Grade 3 complication
Prevention
Complete dissection of the indirect sac off of the sper-
matic cord is not necessary if the sac is long. The sac
can be divided and the proximal end closed with an
endoloop. Dividing the sac at the internal ring fre-
quently helps in the dissection of the remaining sper-
matic cord structures.
Ind
B
Figure 517 A, Left indirect hernia defect (Ind) with contents
nearly completely reduced. Coopers ligament (Coop) has been
exposed, and the inferior epigastric vessels (Inf) have been seen.
B, Corresponding pictorial view.
Placement of Mesh
Avoiding Recurrence
The mesh should be large enough to cover all potential
hernia defects in the groin. It is also important to x the
mesh to minimize shrinkage and to prevent migration.
Inappropriate mesh placement can lead to hernia recur-
rence because the mesh shrinks over time and can move
within the preperitoneal space. The mesh also needs to lie
at against the anterior abdominal wall in order to prevent
hernia recurrence around the edges of the mesh.
Consequence
Laparoscopic hernia repair should have similar or lower
recurrence rates than those of open operation.
Grade 3 complication
 520 SECTION VIII: HERNIA
Figure 518 Mesh placement in right direct hernia repair.
Repair
If a hernia recurs, it can be re-repaired with either an
open or a laparoscopic technique.
Prevention
Using a large piece of mesh and xing the mesh decrease
the chance of recurrence. Enough space should be dis-
sected out laterally in order for the mesh to lie at
against the abdominal wall. The edge of dissected peri-
toneum should be beyond the edge of the mesh to
prevent recurrence.
When repairing direct hernias, preformed, contoured
mesh (Bard, 3D Max Mesh, Davol Inc., Cranston, RI)
can be used (Fig. 518). The contoured surface and stiff-
ness of the mesh make it easy to manipulate, and it tends
not to move much within the preperitoneal space. For an
indirect hernia, however, we use a large (16 12 cm)
piece of at mesh that is slit medially, passing the lower
tail around the spermatic cord structures (Fig. 519). The
two tails are then overlapped and xed to Coopers liga-
ment medially. Slitting the mesh medially and placing the
lower tail below the cord structures ensures complete
coverage of the indirect inguinal hernia site without having
to add additional points of xation of the mesh.
Fixating the Mesh
Consequence
Unxed mesh can move and compromise the repair.
The mesh is usually xed with an endotacker in two
or three points. Inappropriate placement of the tacks,
however, can cause painful neuralgias.
Grade 2/3 complication
Figure 519 Mesh placement in right indirect hernia repair.
Repair
When a specic nerve is entrapped or injured, it can be
diagnosed by pain in its distribution immediately after
the operation. In such cases, the tacks should be
removed.
Prevention
The mesh is xated medially at Coopers ligament and
laterally onto the anterior abdominal wall above the
iliopubic tract (Fig. 5110). Deep tacking into the
pubic bone, instead of Coopers ligament, can cause
chronic pain. There are several nerves at risk for injury
by the tacks as well (Fig. 5111). These nerves run at
or below the iliopubic tract to innervate the upper
thigh. When placing the tacks laterally onto the abdom-
inal wall, the surgeon needs to be able to palpate the
end of the tacking device with the opposite hand. If
the tip is not palpable, the tacks can be placed below
the iliopubic tract and cause nerve injury.
The tacks are designed to simply hold the mesh in place.
Do not use excessive force on the tacking device because
the tacks can cause skin dimpling or even puncture the
skin in very thin persons. After palpating the endotacker
tip, gently push and simply allow the tack to hold the
mesh in place against the anterior abdominal wall.
SUCCESSFUL LAPAROSCOPIC
INGUINAL HERNIA REPAIR
Select appropriate patients
Understand preperitoneal anatomy
Use proven techniques
Avoid common pitfalls
Learn from experience
 51 LAPAROSCOPIC INGUINAL HERNIA REPAIR 521

Genital branch

Femoral branch

Lateral femoral
cutaneous
nerve

A
Genital femoral
nerve
Figure 5111 Nerves at risk for injury during laparoscopic ingui-
nal hernia repair.

REFERENCES

1. Ger R, Monroe K, Duvivier R, Mishrick A. Management of

indirect inguinal hernias by laparoscopic closure of the neck
of the sac. Am J Surg 1990;159:370373.
2. Schultz L, Cartuill J, Graber JN, Hickok DF. Transabdom-
inal preperitoneal procedure. Semin Laparosc Surg 1994;1:
98105.
3. Kingsley D, Vogt DM, Nelson MT, et al. Laparoscopic
intraperitoneal onlay inguinal herniorrhaphy. Am J Surg
B
1998;176:548553.
4. Conlon KC, Johnston SM. Surgical endoscopy for staging
palliation of upper gastrointestinal malignancy. In Soper
NJ, Swanstrom LL, Eubanks WS (eds). Mastery of Endo-
scopic and Laparoscopic Surgery. Philadelphia: Lippincott
Williams & Wilkins, 2005; p 50.
5. Liem MS, van der Graaf Y, van Steensel CJ, et al. Compari-
son of conventional anterior surgery and laparoscopic
surgery for inguinal-hernia repair. N Engl J Med 1997;336:
15411547.
6. Andersson B, Hallen M, Leveau P, et al. Laparoscopic
extraperitoneal inguinal hernia repair versus open mesh
repair: a prospective randomized controlled trial. Surgery
2003;133:464472.
7. Neumayer L, Giobbie-Hurder A, Jonasson O, et al, and
the Veterans Affairs Cooperative Studies Program 456
Investigators. Open mesh versus laparoscopic mesh repair
C of inguinal hernia. N Engl J Med 2004;350:18191827.
Epub 2004; April 25.
Figure 5110 A, Medial mesh xation over a left-sided inguinal
8. Grunwaldt L, Schwaitzberg SD, Rattner DW, Jones DB. Is
hernia defect. Two endotacks are placed in Coopers ligament.
laparoscopic inguinal hernia repair an operation of the past?
B, Lateral mesh xation over a left-sided inguinal hernia defect,
J Am Coll Surg 2005;200:616620.
taking care to place the endotack above the iliopubic tract. The tip
of the tacking device should be palpable with the opposite hand
along the abdominal wall. C, Final orientation of the mesh covering
all left-sided myopectineal orices.
52
Umbilical and Epigastric Hernias
Kamal M. F. Itani, MD
INTRODUCTION
About 10% of all primary hernias consist of umbilical and
epigastric hernias.1 Umbilical hernias are classied into
congenital, infantile, and adult types, based on their actual
time of development in life. This section covers only the
adult umbilical hernia, which in 90% of the cases, is an
acquired hernia and represents an indirect herniation
through the umbilical canal.2
Epigastric hernias are protrusions of the intra-abdomi-
nal contents through the linea alba between the umbilicus
and the xyphoid. The origin and development of the
epigastric hernia is still an enigma. Although originally
considered a congenital defect,3 it is now assumed to be
an acquired lesion.4 It is important to note that as many
as 20% of these hernias are multiple, although it may not
be apparent clinically that more than one hernia exists.5
INDICATIONS
Complications of umbilical hernias are few, with strangu-
lation, incarceration, or evisceration being reported in 5%
of patients in large series.5 Hernias smaller than 1.5 cm in
diameter become incarcerated twice as often as do larger
hernias. The skin over larger hernias is stretched and often
very thin and may even become ulcerated by pressure
necrosis. In cirrhotic patients with ascites, skin ulceration
and necrosis may lead to rupture with chronic ascitic uid
leak or peritonitis. In obese patients, contact dermatitis
with resulting ulceration can occur between the inferior
fold of the hernia and the abdominal wall.
Many patients seek surgery for esthetic reasons and for
relief of discomfort. However, the real danger is the risk
of the previously discussed complications, and repair is
therefore advocated as soon as feasible.
For epigastric hernias, the smaller hernias may become
painful because of strangulation of the preperitoneal fat
incarcerating in the defect. Omentum in the sac may also
strangulate, in which case, the hernia may become swollen,
painful, and tender, and the overlying skin reddens. Larger
hernias containing bowel may also strangulate, but this is
rare. Epigastric hernias are managed in the same way as
umbilical hernias.
OPERATIVE PROCEDURE
Repair of umbilical and epigastric hernias can be per-
formed through the open approach or laparoscopically.
As with incisional hernias, smaller umbilical and epigastric
hernias (<3 cm) can be repaired with primary tissue
approximation with sutures.6 Repair of larger defects gen-
erally requires the use of prosthetic materials, which allow
for a tension-free repair. Laparoscopic techniques may be
used for repair of hernias greater than 3 cm in diameter,
recurrent hernias of any size, hernias in obese patients and
in those who had to return to strenuous activity shortly
after surgery.7
Open Repair
The classic repair for umbilical hernias is the Mayo her-
nioplasty.8 In this operation, a vest-over-pants imbrication
of the superior and inferior aponeurotic segments is per-
formed. Smaller umbilical and epigastric hernias are closed
with a to-and-fro continuous or interrupted nonabsorb-
able suture (Fig. 521).
Prosthetic Mesh Repair
Mesh repair for umbilical and epigastric hernias can be
used as sublay or onlay. Mesh plugs have also been used
to repair these hernias. In the sublay technique, the Rives-
Stoppa repair described for ventral incisional hernias is
used in which the mesh is placed between the rectus
abdominis muscle and the posterior rectus sheath
(Fig. 522). With the onlay technique, the defect is pri-
marily closed as described previously for primary repair
and an onlay mesh is sutured circumferentially on top of
the primary repair to reinforce the defect (Fig. 523).
A mesh plug has also been used with care to avoid
placing the plug in direct contact with bowel. The sac is
carefully dissected and reduced. The preperitoneal space
is dissected to allow placement of the mesh in that space.
The mesh plug is subsequently sutured to the fascial edges
(Fig. 524).
The Prolene hernia system has been successfully used
recently to repair umbilical and epigastric hernias. The
Prolene hernia system combines a sublay, a plug, and an
 524 SECTION VIII: HERNIA

MC
A B

C D
Figure 521 Primary repair of a small umbilical hernia with interrupted monolament suture. A, Infraumbilical curvilinear incision and
(B) primary repair with either (C) a running monolament suture or (D) interrupted monolament sutures.

A B
Figure 522 Rives-Stoppa repair with a sublay mesh placed between the rectus abdominis muscle and the posterior rectus sheath.
A, Anterior and (B) sagittal view of the sublay mesh with anchoring transmuscular sutures.
 52 UMBILICAL AND EPIGASTRIC HERNIAS 525

A B
Figure 523 Continuous or interrupted mass closure of hernia opening (A) with onlay reinforcement of the repair with mesh sutured
circumferentially (B).

A B
Figure 524 Mesh plug repair. A, The mesh is placed in the preperitoneal space after dissection and reduction of the hernia sac.
B, The mesh is sutured to the fascial edges.

onlay repair. The posterior leaet of the Prolene hernia
system is placed in the preperitoneal space after carefully
reducing the sac and dissecting the preperitoneal space
underneath the fascial edges. The connector between the
posterior and the anterior leaet of the mesh acts as a plug.
The anterior leaet of the Prolene hernia system is tacked
to the anterior rectus fascia with running or interrupted
nonabsorbable monolament sutures (Fig. 525).
The laparoscopic repair uses the concept of a sublay
technique with a smooth mesh used intraperitoneally with
a 3- to 4-cm overlap over the edges of the defect. Trans-
abdominal xation of the mesh with nonabsorbable sutures
every 6 cm in addition to the tacks has been shown to
reduce recurrence. Although various prosthetic materials
have been used in contaminated elds, it is advisable to
avoid their use under this condition and perform a primary
suture repair or use allografts (Fig. 526).
Complications
Recurrence of Hernia
One of the most signicant problems in hernia surgery is
recurrence. Recurrence rates as high as 13% have been
reported for umbilical hernias repaired primarily without
mesh.9
Consequence
Recurrence will defeat the purpose of the original
primary repair. Subsequent repairs are generally more
difcult and place the patient at higher risk for higher
recurrence rates in the future.10
Grade 3 complication
Repair
Placement of a mesh should be considered in the repair
of a recurrent hernia in which the original defect was
 526 SECTION VIII: HERNIA
Skin
Subcuaneous fat Umbilicus
Subcutis Connector of PHS
Peritoneum
Figure 526 Intraperitoneal placement of a polytetrauoroe-
thylene (PTFE) mesh during laparoscopic repair of an epigastric
hernia. The mesh is xed to the abdominal wall with a nonabsorb-
able suture every 6 cm in addition to tacks circumferentially.
closed primarily. Laparoscopic repair might allow for
an alternative approach and avoid dissection of scarred
tissues if the open approach was originally used. Alter-
natively, an open approach in a recurrent laparoscopic
hernia might avoid intra-abdominal adhesions and
should be used by surgeons with little laparoscopic
experience.
Prevention
Among open repairs, the Mayo technique is no longer
favored11 owing to high recurrence rates ranging
between 20% and 28%.12 The use of mesh in umbilical
or epigastric hernias should reduce the recurrence rate
from 13%9 to less than 1%.13 In a prospective, random-
ized trial comparing primary suture repair with poly-
propylene mesh or plug in 200 patients with a primary
umbilical hernia and a mean follow-up of 69 months,
recurrence was 11% in the primary repair group and 1%
Onlay patch of PHs
Anterior rectus sheath
Musculus rectus Figure 525 Prolene hernia system.
abdominis The posterior leaet of the mesh is placed
in the preperitoneal space. The anterior
Underlay of leaet of the mesh is anchored to the
patch of PHS anterior rectus fascia.
in the mesh repair group. Overall recurrence rates were
similar for defects greater and smaller than 3 cm diam-
eter (8% vs. 5%, respectively).14
There are no studies that evaluate the recurrence rate
of sublay repair and few reported with onlay mesh in the
repair of primary umbilical or epigastric hernias. The
sublay technique requires extensive preparation of the pre-
peritoneal space. Recurrence rates of 0%15 to 10.4%16 have
been reported with this technique in ventral incisional
hernias. With the onlay mesh, recurrence varies from
2.5%17 to 14.8%18 in ventral incisional hernias and 0% in
a small series of primary umbilical hernias.19 With the plug
repair, no recurrence has been reported for primary umbil-
ical and epigastric hernias; a recurrence rate of 2.3% was
reported for the repair of recurrent umbilical hernias, and
0% was reported for the repair of recurrent epigastric
hernias.20 With the Prolene hernia system, recurrence has
been reported to be 0%.19,21
The laparoscopic repair is gaining popularity with larger
(>3 cm) umbilical and epigastric hernias. Recurrence rate
was nonexistent in two small series with less than 2 years
follow-up.22,23 No relationship has been observed between
obesity and recurrence.9
Seroma
Seroma occurs in 2.9% of open umbilical hernia repairs
and 3.5% of open epigastric hernia repairs.20 The incidence
of seroma in the laparoscopic group is higher, at 10%.22
Consequence
Seromas can be tender or uncomfortable to the patient.
They can also become secondarily infected in both the
open and the laparoscopic procedures, ultimately
requiring removal of the mesh and recurrence of the
ventral hernia. Treatment by aspiration or repeated
aspiration of the seroma can be uncomfortable and
annoying to the patient and has the risk of introducing
bacteria.
Grade 2 complication
 52 UMBILICAL AND EPIGASTRIC HERNIAS
Repair
Most seromas will resolve with expectant therapy. Symp-
tomatic seromas, large seromas, and persistent seromas
can be aspirated; repeated aspirations might be required.
A chronic seroma might need operative intervention
using the open or laparoscopic approach with drain-
age of the uid and removal of the pseudocapsule.
Prevention
Placement of subcutaneous drains has been advocated
in the open repair that requires extensive dissection and
development of aps in order to prevent uid accumu-
lation and seroma. The use of a pressure dressing with
a binder for 7 to 10 days after laparoscopic repair has
also been advocated.24 Premature removal of a drain
can result in uid accumulation; however, this should
be weighed against leaving a drain for a prolonged
period of time with the potential for an infection to
occur. It is believed that repeated aspiration of the uid
in a third of the patients is less morbid than placement
of a drain in all patients undergoing the laparoscopic
procedure. A small study suggested that cauterization
of the hernia sac during the laparoscopic repair prevents
seroma formation.25
Infection
Despite the use of prophylactic antibiotics and advances in
anesthesia techniques, infection rates of 3.3% with laparo-
scopic and 10% with open repair are still reported for umbil-
ical and epigastric hernia repairs.22 Body habitus, diabetes,
immunosuppression, and cigarette smoking are all risk
factors for a surgical site infection in these patients.
Consequence
Postoperative cellulitis occurring around the incision is
self-limited and usually resolves with oral or intrave-
nous antibiotics. When unrecognized, it can progress
to a deep surgical site infection.
Grade 1/2 complication
Repair
In cases of cellulitis, antibiotic therapy is recommended
until resolution of the redness and return of the tem-
perature and white blood cell to normal. In cases of
abscesses with no mesh placement, percutaneous or
open drainage with local wound care and antibiotics
should be performed. In the presence of a mesh, open
drainage and removal of the mesh should be consid-
ered; in the cases of polypropylene mesh, consider-
ation can be given to leaving the mesh in place and
applying local wound care with wet to dry dressings
and antibiotic therapy. All necrotic tissue should be
dbrided.
Prevention
Intravenous antibiotic prophylaxis within 60 minutes
of incision time is recommended in patients at higher
527
risk for infection undergoing mesh placement.26
Optimization of patient risk factors and adequate prep-
aration of the surgical site should be observed.26 No
relationship was found between wound infection and
obesity.
Hematoma
Hematomas are most commonly the result of trocar injury
to abdominal wall vessels in the laparoscopic repair. In the
open repair, hematomas are due to poor hemostasis at the
time of dissection of the subcutaneous aps. Hematomas
in both procedures can also be the result of intra-
abdominal organ or mesenteric injury.
Consequence
Hematomas have been associated with pain at the surgi-
cal site, wound infections, intra-abdominal abscess for-
mation, need for reexploration, and blood transfusion.
Grade 1/2 complication
Repair
Most hematomas can be treated expectantly. Progres-
sion of a hematoma with a continuous drop in hema-
tocrit will require reexploration of the surgical site,
ligation of the bleeder, and proper hemostasis. Hema-
tomas that are symptomatic or infected will need to be
drained. A liqueed hematoma can be aspirated if
symptomatic or persistent.
Prevention
Proper surgical technique and cauterization or ligation
of all bleeders should be performed. Blunt dissection
in the preperitoneal space can result in unrecognized
bleeding. Inspection of all entered spaces for adequate
hemostasis should be performed prior to nal closure.
Bowel Injury, Intra-abdominal Abscess,
Enterocutaneous Fistula
Unrecognized serosal tear during laparoscopic dissection,
placement of a polyester or polypropylene mesh within
the peritoneal cavity, or migration of a plug into the
peritoneal cavity can all result in bowel perforation, post-
operative intraperitoneal abscess, and/or delayed entero-
cutaneous stulas.
Consequence
When this complication occurs, removal of the mesh
with recurrence of the hernia is inevitable. Resection of
the involved bowel is necessary.
Grade 3 complication
Repair
Percutaneous drainage of an intra-abdominal abscess,
antibiotic therapy, and stabilization of the septic pati-
ent should be performed. Spontaneous closure of
an enterocutaneous stula secondary to bowel injury
during the hernia repair or mesh erosion will not occur.
 528 SECTION VIII: HERNIA
In these cases, removal of the mesh and resection of
the involved loop of bowel is the next step. The use of
a bioprosthesis to bridge the fascial defect and prevent
the recurrence of a hernia should be considered but is
not proved to prevent hernia recurrence in the long
term.
Prevention
The use of polypropylene and polyester meshes within
the peritoneal cavity should be avoided and restricted
to the preperitoneal space. In the laparoscopic repair,
polytetrauoroethylene should be used. Newer mate-
rial such as allografts and combined material (Proceed)
are under consideration. Inspection of the bowel for
any sign of injury should be performed during laparo-
scopic cases and in open procedures in which the peri-
toneal cavity is entered.
Skin Necrosis
Skin necrosis is rare and is the result of devascularization
of the skin aps at the time of dissection.
Consequence
Although small areas of skin necrosis can be self-limited,
larger areas might get secondarily infected or result in
skin dehiscence.
Grade 1/2 complication
Repair
Areas of skin necrosis will usually require skin dbride-
ment and local care of the wound. In cases of infection,
it should be treated as described previously. With mesh
exposure, consideration should be given to ap advance-
ment or skin grafting if the involved area is large and
after proper granulation.
Prevention
Dissection of the skin and subcutaneous tissue ap
should be carefully undertaken in order to avoid devas-
cularization of the aps and subsequent skin necrosis.
Umbilical Hernia Repair in Patients with
End-Stage Liver Disease and Refractory Ascites
Umbilical hernia is seen in up to 20% of patients with
longstanding cirrhosis and ascites27 (Fig. 527). The strat-
egy for treating umbilical hernia in patients with ascites
has evolved considerably. Initial management consisted of
nonoperative therapy secondary to fear of precipitating
bleeding from esophageal varices.
Consequence
Occasionally, a patient will present with spontaneous
rupture of an umbilical hernia and leaking ascites.
Patients with ascites who present acutely with ruptured
umbilical hernias have two distinct problems that need
to be treated, namely, the ruptured umbilical hernia
and the underlying ascites.
Grade 3 complication
Figure 527 Patient with intractable ascites and protruding
umbilical hernia at risk for rupture (Reproduced with permission
from www.mef.hr/patologija/ch_3/c3_ascites_umb_hernia.jpg).
Repair
Prevention of infection and adequate uid and electro-
lyte management in ruptured umbilical hernias in
cirrhotic patients with ascites are crucial. Management
of ascites with transjugular intrahepatic portosystemic
shunting (TIPS) is currently favored, followed by repair
of the umbilical hernia.
Prevention
Elective repair of an umbilical hernia in patients with
ascites should be performed after proper optimization
of the patient.
Aggressive medical management of ascites with diuret-
ics is advocated prior to elective hernia repair. In cases of
refractory ascites, the treatment of choice becomes primary
repair of the hernia with either concomitant or staged
peritoneovenous shunting (PVS).27 Recently, transjugular
intrahepatic portosystemic shunting (TIPS) has supplanted
PVS as the treatment of choice in patients with intractable
ascites prior to umbilical hernia repair.28
REFERENCES
1. Muschaweck U. Umbilical and epigastric hernia repair.
Surg Clin North Am 2003;83:12071221.
2. Jackson OJ, Moglen LH. Umbilical hernia: a retrospective
study. Calif Med 1970;113:8.
3. Larson GM, Vandertoll MD. Approaches to repair of
ventral hernia and full thickness losses of the abdominal
wall. Surg Clin North Am 1978;60:4042.
4. Lang B, Lau H, Lee F. Epigastric hernia and its etiology.
Hernia 2002;6:148150.
5. Nyhus LM, Pollack R. Epigastric, umbilical, and ventral
hernias. In Decker BC (ed): Current Surgical Therapy. St.
Louis: Mosby, 1992; pp 536539.
6. SSAT Patient Care Guidelines. Surgical repair of incisional
hernias. J Gastrointest Surg 2004;8:369370.
7. Evidence mounts for lap umbilical hernia repair. Two
hernia giants report their ndings. Gen Surg News
 52 UMBILICAL AND EPIGASTRIC HERNIAS
2002;29:1415. Available at www.generalsurgerynews.com
(accessed October 2002).
8. Mayo WJ. An operation for the radical cure of umbilical
hernia. Ann Surg 1901;34:276278.
9. Holm JA, Heisterkamp J, Veen HF, et al. Long term
follow-up after umbilical hernia repair: are there risk
factors for recurrence after simple and much repair?
Hernia 2005;26:14.
10. Flum DR, Horvath K, Koepsell T. Have outcomes of
incisional hernia repair improved with time? A population
based analysis. Am Surg 2003;237:129135.
11. Bennett D. Incidence and management of primary
abdominal wall hernias: umbilical epigastric and spigelian.
In Fitzgibbons RJ Jr, Greenburg AG (eds): Nyhus and
Condons Hernia, 5th ed. Philadelphia: JB Lippincott,
2002; pp 389398.
12. Celdran A, Bazire P, Garcia-Urena MA, et al. Hernio-
plasty: a tension free repair for umbilical hernia. Br J Surg
1995;82:371372.
13. Arroyo SA, Perez F, Serrano P, et al. Is prosthetic
umbilical hernia repair bound to replace primary hernior-
rhaphy in the adult patient? Hernia 2002;6:175
177.
14. Arroyo A, Garcia P, Perez F, et al. Randomized clinical
trial comparing suture and mesh repair of umbilical hernia
in adults. Br J Surg 2001;88:13211323.
15. Bauer JJ, Harris MT, Gorne SR, et al. Rives-Stoppa
procedure for repair of large incisional hernias. Experience
with 57 patients. Hernia 2002;6:120123.
16. Petersen S, Henke G, Freitag M, et al. Experiences with
reconstruction of large abdominal wall cicatricial hernias
using Stoppa-Rives pre peritoneal meshplasty. Zentralbl
Chir 2000;125:152156.
529
17. Kennedy GM, Matyas JA. Use of expanded polytetrouo-
roethylene in the repair of the difcult hernia. Am J Surg
1994;168:304306.
18. Leber GE, Garb J, Albert A, Reed WP. Long-term
complications associated with prosthetic repair of inci-
sional hernias. Arch Surg 1998;133:378382.
19. Cafer P, Dervisoglu A, Senyurek G, et al. Umbilical hernia
repair with the Prolene hernia system. Am J Surg 2005;
190:6164.
20. Muscharveck U. Umbilical and epigastric hernia repair.
Surg Clin North Am 2003;83:12071221.
21. Perrakis E, Velimezis G, Vezakis A, et al. A new tension-
free technique for the repair of umbilical hernia, using the
Prolene hernia systemearly results from 48 cases. Hernia
2003;7:178180.
22. Wright BE, Beckerman J, Cohen M, et al. Is laparoscopic
umbilical hernia repair with mesh a reasonable alternative
to conventional repair? Am J Surg 2002;184:505508.
23. Lou H, Patil NG. Umbilical hernia in adults. Surg Endosc
2003;17:20162020.
24. Chowbey PK, Sharma A, Khullar R, et al. Laparoscopic
ventral hernia repair. J Laparoendosc Adv Surgl Tech
2000;10:7984.
25. Tsimoyiannis EC, Siakas P, Glantzounis G, et al. Seroma
in laparoscopic ventral hernioplasty. Surg Laparosc Endosc
Percutan Tech 2001;11:317321.
26. Barie PS, Eachempati SR. Surgical site infections. Surg
Clin North Am 2005;85:11151135.
27. Belghetti J, Durand F. Abdominal wall hernias in the
setting of cirrhosis. Semin Liver Dis 1997;17:219226.
28. Fagan SP, Awad SS, Berger DH. Management of compli-
cated umbilical hernias in patients with end stage liver
disease and refractory ascites. Surgery 2004;135:679682.
53
Open Primary and Mesh Repairs
Mary Hawn, MD
INTRODUCTION
Incisional hernias complicate approximately 10% of all
laparotomies. Repair of an incisional hernia is a challeng-
ing case and recurrence rates remain high. The rst repair
of an incisional hernia has the highest likelihood of success;
therefore, considerable attention should be given to the
surgical strategies that achieve optimal outcomes.1 The
key factor associated with decreased likelihood of recur-
rence is the use of mesh for the repair.2 Long-term results
of a randomized trial comparing suture with mesh repair
demonstrated a 62% recurrence for suture repair and 32%
for mesh repair.3 For small defects (<10 cm2), the efcacy
of mesh was even greater, with a 67% recurrence in the
suture arm and 17% in the mesh arm. This highlights the
fact that even small hernias should have a mesh repair.
However, mesh is associated with a twofold increase in
the complication rate, some of which, such as mesh infec-
tion and stula formation, can be devastating.3 Therefore,
it is important to understand factors associated with
increased risk of mesh complications.
Primary reapproximation of the fascial edges without a
mesh overlay or component separation technique should
be reserved for patients with a contraindication to mesh
placement and, given the current literature, should not be
considered a denitive hernia repair. Many different tech-
nical approaches to mesh placement are available, and they
can essentially be divided into three categories: (1) intra-
abdominal (underlay), (2) interfascial (interlay), and (3)
suprafascial (overlay). We have an ongoing study of inci-
sional hernia repairs performed in the Veterans healthcare
system, and all three types of open repair are used equiv-
alently. Without adequate outcomes data, we currently
cannot advocate one approach over the other.
INDICATION
Presence of an incisional hernia
PREOPERATIVE CONSIDERATIONS
1. Misdiagnosis. Eventration can be difcult to distinguish
from herniation, especially in obese patients.
a. Diastasis recti. Upper midline attenuation of linea
alba.
b. Lateral eventration. Most often seen after ank inci-
sions for nephrectomy and results from denervation
of the oblique musculature. A computed tomogra-
phy (CT) scan can be useful in conrming the diag-
nosis of eventration.
2. Prior surgical history
a. History of cancer
i. Does the patient need to be restaged? Will you
need to biopsy tissue during your laparotomy?
b. Presence of an ostomy
i. Can it be reversed? If so, these patients should be
evaluated for concomitant ostomy reversal.
ii. Consider a bowel preparation preoperatively.
c. Prior mesh placement
i. Important to review prior operative notes to un-
derstand where the mesh was placed and what
type of mesh was used.
3. Contraindications to mesh placement
a. Preexisting infection. Whenever possible, the preex-
isting infection should be denitely treated prior to
hernia repair. Preexisting infection increases the risk
for wound infection and subsequent failure of the
repair (Fig. 531).
b. Concomitant bowel surgery. This is a relative con-
traindication. If the bowel surgery is elective and the
bowel is prepared, mesh can be placed with relative
safety.4
4. Modiable factors that may improve outcome
a. Prostatism. A history of prostatism in men increases
the risk for recurrence.2 Although there are no stud-
ies to evaluate the efcacy of treating the symptoms,
it seems logical to have men with symptoms of pros-
tatism evaluated prior to elective surgery.
b. Smoking cessation. Smoking doubles the risk of sur-
gical site infection.5 Surgical site infection is asso-
ciated with a greater than 50% recurrence rate for
incisional hernia repair.3 If the patient is at high risk,
consideration should be given to smoking cessation
prior to undertaking elective repair.
c. Obesity. Obesity is a risk factor for both surgical
site infection and recurrence. If a patient has failed a
prior repair without other explanation, consideration
 532 SECTION VIII: HERNIA

Figure 532 Infection of mesh prosthesis. Air bubbles (arrow)

are present in the perimesh uid collection.

Figure 531 Incisional hernia with concomitant infection. An wound infection can lead to a hernia recurrence rate of
infected peripancreatic uid collection (arrow) is shown. 80%.3 Furthermore, if the mesh prosthesis becomes
infected, it usually needs to be explanted (Fig. 532).
Grade 2/3 complication
should be given to a weight loss intervention prior
to undertaking repair of a recurrent hernia. Repair
5. Nonmodiable risk factors for recurrence The surgical site needs to be opened and the purulent
a. History of an abdominal aortic aneurysm (AAA). material evacuated. If the infection involved a mesh pro-
Patients with a history of an AAA are at fourfold risk sthesis, especially polytetrauoroethylene (PTFE), it will
for recurrence.2 likely need to be explanted and either a primary fascial
b. Chronic steroid use is associated with a fourfold closure or an absorbable mesh placement performed.
increase in postoperative wound infections.5
Prevention
Preoperative antibiotics. A randomized trial has shown
OPERATIVE STEPS that a single dose of preoperative antibiotics decreases
the incidence of postoperative surgical site infections
Step 1 Preparation of patient for incisional hernia repair.6 Gram-positive coverage is
Step 2 Excise old scar sufcient unless concomitant bowel resection is planned.
Step 3 Excise peritoneal hernia sac from subcutaneous Antimicrobial skin barrier (Ioban) or other skin barrier
tissue to limit the direct contact of the prosthesis with the
Step 4 Identify fascial edges and raise subcutaneous patients skin.7
aps
Step 5 Reduce hernia contents to abdominal cavity,
Denition of the Facial Edges
sharp adhesiolysis if necessary Missed concomitant defect or inadequate overlap between
Step 6 Placement of mesh prosthesis or component mesh and fascia.
separation repair
Step 7 Drain subcutaneous space Consequence
Step 8 Skin closure The rate of hernia recurrence after incisional hernia
repair remains high. Common causes for hernia recur-
rence are the failure to recognize or repair all defects
OPERATIVE PROCEDURE at the time of the initial surgery and inadequate overlay
of mesh with the repair2 (Fig. 533).
Preparation of the Patient Grade 3 complication
Wound Infection
Repair
Consequence Operative repair of the recurrent hernia may be under-
Wound infections are a signicant morbidity for inci- taken. Repair of recurrent hernias is less likely to be
sional hernia repair. The occurrence of a postoperative successful and is associated with more complications.1
 53 OPEN PRIMARY AND MESH REPAIRS
Figure 533 A, Recurrent incisional hernia after prior mesh
repair. Intact mesh overlay (arrow) is shown. B, Incarcerated bowel
(arrow) is shown between the fascia and the mesh.
Prevention
Raise subcutaneous aps circumferentially for at least 3
to 5 cm from the hernia defect to expose healthy fascia.
If an underlay technique is employed, lyse adhesions
from the undersurface of the peritoneum for at least
5 cm from the hernia defect. Palpate cephalad and
caudad to the hernia defect to ensure that there are not
any concomitant defects.
Adhesiolysis and Reduction of Hernia Contents
Enterotomy or Deserosalization
Consequence
Intestinal contents may be in the subcutaneous tissue,
and thermal injury to the bowel from cautery can
increase the risk of postoperative intestinal leak and
stula. An unrecognized or missed enterotomy may
result in sepsis and death. Repair of a recognized enter-
533
otomy increases the complexity of the operation and
potentially increases the risk of mesh infection.
Grade 3/4 complication
Repair
Prior to closure of the abdomen, all of the intestine
should be inspected for evidence of inadvertent injury
or deserosilization.
Prevention
Careful, sharp dissection for the adhesiolysis of intes-
tine is recommended. Avoid using cautery to take down
dense intestinal adhesions to prevent thermal injury to
the intestine. Prompt repair of any recognized enter-
otomies or deserosilation should be undertaken. If
multiple enterotomies are made in a short segment of
bowel, or if the enterotomy comprises more than 50%
of the bowel circumference, consideration should be
given to resecting that portion of the intestine.
Enterocutaneous Fistula
Consequence
Intestinal stulas occur more frequently with mesh
repair, and the incidence appears to be approximately
2% to 4%.3 Intestinal stulas in combination with a
ventral hernia are very difcult to manage and are dis-
cussed in more detail later in this chapter.
Grade 3/4 complication
Repair
All enterocutaneous stulas involving a foreign body
will require removal of the foreign body and operative
repair. If the stula is distal in the small intestine or
involves the colon and can be adequately managed with
an ostomy appliance, conservative therapy can be
considered.
Prevention
Enterocutaneous stulas are believed to result from
erosion of the mesh prosthesis into the adjacent intes-
tine. Therefore, omentum, peritoneum, or fascia
should be placed between the intestine and the mesh.
If this is not possible, then an expanded PTFE
(ePTFE) mesh appears to have the lowest rate of stula
formation.8
Placement of the Mesh Prosthesis
Mesh to Skin Fistula
Consequence
A chronic sinus tract between the mesh and the skin is
inconvenient for the patient but does not mandate
mesh removal (Fig. 534).
Grade 1/2 complication
Repair
A course of antibiotics can be attempted and is usually
successful in decreasing the amount of drainage from
 534 SECTION VIII: HERNIA
Figure 534 Mesh sinus tract. Localized mesh infection (solid
arrow) results in a persistent sinus tract. The fascial edges (broken
arrows) illustrate that the majority of the mesh is incorporated and
not infected.
the wound. The sinus tract can be explored and any
unincorporated mesh removed.
Prevention
Excise the old scar and any attenuated or nonviable
skin prior to closure of the incision. Local skin necrosis
can lead to mesh exposure and chronic sinus tract
formation.
Wound Closure
Seroma Formation
Consequence
A seroma causes pain and discomfort for the patient. It
also leads to a cosmetically undesirable outcome. Occa-
sionally, seromas can become infected and need more
aggressive treatment (Fig. 535).
Grade 1/2 complication
Repair
Aspiration of the seroma can usually be performed in
the clinic setting. An abdominal binder can be placed
to help decrease the likelihood of the seroma reform-
ing. Care should be taken to perform the aspiration in
an aseptic manner so that the seroma does not become
secondarily infected.
Prevention
Excise the peritoneal sac from the subcutaneous tissue
and ensure meticulous hemostasis prior to closure.
Place drains at the time of surgery if subcutaneous aps
were raised. Use a closed drainage system to decrease
risk of infection. Consider placing an abdominal binder
to decrease the likelihood of seroma formation.
Figure 535 Subcutaneous seroma after primary incisional hernia
repair (arrow). This collection was aspirated and was sterile. A
percutaneous drain was placed and resulted in resolution of the
collection.
Figure 536 Off-midline incisional hernia with concomitant loss
of abdominal domain (arrow).
Special Considerations at the Time of
Incisional Hernia Repair
Emergency Repair with Concomitant
Bowel Obstruction
Patients who present with obstructed or strangulated
intestine present several challenges for incisional hernia
repair. Any nonviable bowel should be resected. If the
small bowel is involved and the patient is stable, primary
anastomosis is preferable. If the large intestine is involved
or the patient is unstable, creation of an ostomy and
mucous stula or Hartmans pouch is the safest approach.
If the eld is contaminated, a primary closure with or
without reinforcement of an absorbable mesh should be
performed. If there is too much tension on the repair
owing to either the size of the defect or the dilated intes-
tine, a mesh repair can be performed to prevent facial
dehiscence postoperatively. If any intraoperative enteroto-
 53 OPEN PRIMARY AND MESH REPAIRS
mies or bowel resections occurred, that bowel should be
protected from the fascial closure when possible. Entero-
cutaneous stulas are much more likely to develop if a
repaired enterotomy is present immediately below a fascial
or mesh repair.
Off-Midline Hernias
The challenges for off-midline hernias include (1) expo-
sure of the defect, (2) ability to deal with intraoperative
535
complications, and (3) nding adequate tissue to secure
the repair (Fig. 536). Off-midline hernias in the ank
position are best repaired with the patient in the decubitus
position, whereas an off-midline hernia in a prior chole-
cystectomy or ostomy site incision is best approached with
the patient supine. Flank hernias often require securing
the mesh to the rib cage or the iliac crest. MiTek screws
can be used to secure the mesh repair to these bony
structures.
Figure 537 A, Extra-abdominal repair of enterocutaneous stula
with an incisional hernia. Computed tomography (CT) scan demon-
strates stula arising in the hernia defect (arrow). B, Rectus femoris
ap raised in preparation for stula (arrow) closure. C, Completion
of the closure with 14-Fr red rubber catheter through the rectus
femoris ap and stula.
 536 SECTION VIII: HERNIA
Loss of Domain and/or Loss of Abdominal Wall
Loss of domain occurs when a signicant amount of the
intra-abdominal contents are chronically incarcerated in
the hernia sac (see Fig. 536). Returning these contents
to the abdominal cavity at the time of repair will increase
the intra-abdominal pressure. This can both cause undue
tension on the repair and increase the risk for dehiscence
and also pulmonary compromise from the increased pres-
sure on the diaphragm. Peak airway pressures should be
monitored before and after the fascial repair to help deter-
mine whether pulmonary compromise is a risk postopera-
tively. Likewise, loss of abdominal wall, from either prior
fasciitis or retraction of the muscles laterally, will require
signicant aps to be raised to identify adequate fascial
edges to secure the repair.
Fistula
An enterocutaneous stula signicantly increases the com-
plexity of ventral hernia repair. All considerations of factors
that impede stula closure must be addressed. Particular
scenarios often seen in this setting are the presence of
either a foreign body, especially prior mesh placement, or
a short stula track owing to lack of fascia at the hernia
site. A stula in the presence of a prosthetic material will
not close until the foreign body is removed and the stula
repaired. Every attempt must be made to get muscle or
fascia directly over the stula repair, or the likelihood of
success is low. This is a scenario in which component
separation is very useful to provide autogenous muscle
and/or fascia for the closure.
If a stula is present in the middle of a granulating
wound without mesh or distal obstruction, consideration
can be given to a ap repair to close the stula.9 This
extra-abdominal repair has a high rate of success for stula
closure, but it does not address repair of the underlying
hernia. We have used this technique successfully to close
stulas when the patient has a signicant loss of abdomi-
nal wall and no evidence of distal obstruction (Fig. 537).
The basis of this technique is to take a short, likely epi-
thelialized tract and convert it into a long tract. We have
used both rectus abdominus and rectus femorus muscle
rotational aps. We raise subcutaneous aps around the
stula and abdominal wall defect. We then freshen up the
edges of the stula and place a pursestring suture around
the edges. We then place a 14-Fr red rubber Robinson
catheter through the skin and muscle ap into the intes-
tine, much like a feeding jejunostomy tube. The ap is
then inset, and the tube is left to dependent drainage for
2 weeks. The tube is then removed, and if successful, the
tract closes.
SUMMARY
In summary, incisional hernia repair is a commonly per-
formed operation. There are no gold standards for tech-
nique of repair. Complications presenting at the time of
incisional hernia repair or as a consequence of the repair
pose major challenges for treatment.
REFERENCES
1. Flum DR, Horvath K, Koepsell T. Have outcomes of
incisional hernia repair improved with time? A population-
based analysis. Ann Surg 2003;237:129135.
2. Luijendijk RW, Hop WC, van den Tol MP, et al. A
comparison of suture repair with mesh repair for incisional
hernia. N Engl J Med 2000;343:392398.
3. Burger JW, Luijendijk RW, Hop WC, et al. Long-term
follow-up of a randomized controlled trial of suture versus
mesh repair of incisional hernia. Ann Surg 2004;240:578
583; discussion 583585.
4. Geisler DJ, Reilly JC, Vaughan SG, et al. Safety and
outcome of use of nonabsorbable mesh for repair of fascial
defects in the presence of open bowel. Dis Colon Rectum
2003;46:11181123.
5. Finan KR, Vick CC, Kiefe CI, et al. Predictors of wound
infection in ventral hernia repair. Am J Surg 2005;190:
676681.
6. Abramov D, Jeroukhimov I, Yinnon AM, et al. Antibiotic
prophylaxis in umbilical and incisional hernia repair: a
prospective randomised study. Eur J Surg 1996;162:945
948; discussion 949.
7. French ML, Eitzen HE, Ritter MA. The plastic surgical
adhesive drape: an evaluation of its efcacy as a microbial
barrier. Ann Surg 1976;184:4650.
8. Diaz JJ Jr, Gray BW, Dobson JM, et al. Repair of giant
abdominal hernias: does the type of prosthesis matter?
Am Surg 2004;70:396401; discussion 402.
9. Kearney R, Payne W, Rosemurgy A. Extra-abdominal
closure of enterocutaneous stula. Am Surg 1997;63:406
409.
54
Laparoscopic Incisional
Hernia Repair
Parag Bhanot, MD

INTRODUCTION
Relative
Incisional hernia formation after laparotomy is a complica- Active wound infection
tion that occurs in approximately 20% of patients.1 Several Loss of abdominal domain
open hernia repair methods have been developed, but they Severe abdominal adhesions
are associated with signicant recurrence rates and wound-
related complications secondary to extensive tissue dis-
section.2,3 The application of minimally invasive surgery
techniques has led to the development of laparoscopic OPERATIVE STEPS
methods for repairing incisional hernias. Several compara-
tive studies now demonstrate the high rate of success and Although the technical aspects of LVHR vary, the opera-
low associated morbidity compared with those of the open tion involves a series of well-dened steps.
approach.47
Since they were rst reported in the literature in 1992, Step 1 Patient preparation and positioning
the number of laparoscopic ventral hernia repairs (LVHR) Step 2 Abdominal access
performed has signicantly grown as excellent outcomes Step 3 Trocar placement
have been published. Although complications have been Step 4 Lysis of adhesions
reported to occur less frequently when compared with Step 5 Reduction of hernia contents
those of the open approach, they continue to remain an Step 6 Evaluation of fascial defect
issue, especially in less experienced hands. Heniford and Step 7 Mesh selection and preparation
coworkers8 reported an overall complication rate of 13.2% Step 8 Mesh xation
in a series of 850 patients. Step 9 Trocar removal and fascial closure

INDICATIONS
OPERATIVE PROCEDURE
Hernia defect 4 cm or greater
Recurrent hernia
Abdominal Access and Trocar Placement
Multiple hernias
Morbidly obese individuals Trocar Insertion Injuries
An open or closed technique may be used for access to
the peritoneal cavity. A number of complications can
occur while gaining access to the peritoneal cavity because
CONTRAINDICATIONS
a signicant number of these patients may have had
multiple abdominal procedures. The total number of
Absolute
trocars placed is dependent on several factors, including
Surgeon inexperience the extent of adhesions and the size and location of the
Inability to tolerate general anesthesia hernias. Trocars should be placed at least 5 cm away from
Inability to tolerate laparotomy the fascial defect to allow mesh placement with appropri-
Advanced cardiopulmonary disease ate fascial overlap (Fig. 541).
Uncorrectable coagulopathy Complications of trocar insertion are discussed in
Portal hypertension with abdominal wall varices Section I, Chapter 7, Laparoscopic Surgery.
 538 SECTION VIII: HERNIA
A side. A plane allowing for a safe dissection should be
B
Figure 541 A, Although the mesh has been sized to provide
appropriate overlap to cover the fascial defect, its xation is com-
promised as the edge of the mesh overlaps with one of the 5-mm
trocars. B, The trocars are placed at an appropriate distance from
the fascial defect to allow circumferential xation of the mesh.
Lysis of Adhesions
Intestinal Injury
Adhesiolysis can be the most difcult and technically chal-
lenging portion of the operation. This is especially evident
in patients with multiple previous surgeries and/or previ-
ously placed mesh. Soper and associates9 reported their
results of 121 consecutive patients that showed an enter-
otomy rate of 11.4% in patients with prior hernia repairs
compared with 0% in patients undergoing a rst-time
repair.9
Consequence
An enterotomy can jeopardize the remainder of the
operation by affecting the ability to proceed with mesh
placement. This is dependent on the degree of con-
tamination and the portion of the bowel injured. An
unrecognized bowel injury can have catastrophic con-
sequences with resultant intra-abdominal sepsis.
Grade 3/4/5 complication
Repair
The decision on the approach used to repair the bowel
injury is based on surgeon experience and degree of
contamination. Conversion to an entirely open proce-
dure should not be considered a failure. Alternatively, a
smaller incision can be used to allow repair of the enter-
otomy followed by continuation of the laparoscopic
approach. With increasing surgeon experience, a lapa-
roscopic repair of the enterotomy may be performed.
Prevention
A complete visualization of all of the adhesions is
critical to ascertain whether or not bowel is adherent
to the abdominal wall (Fig. 542A). This usually
requires changing the camera port to the contralateral
developed between the abdominal wall and the adhe-
sions. A majority of the dissection should be performed
without the use of energy sources such as ultrasonic
shears, especially adjacent to the bowel wall, to prevent
thermal injury (see Fig. 542B and C). If dense adhe-
sions are present, dividing the hernia sac or adjacent
fascia may aid the adhesiolysis (see Fig. 542D). The
surgeon should avoid grasping the bowel directly
and instead use the surrounding adhesions to provide
countertraction.
Hemorrhage
Minimal bleeding can result from a number of sources.
However, signicant bleeding is rare and usually recog-
nized intraoperatively. Major sources are raw surfaces of
the abdominal wall after extensive adhesiolysis, injury to
abdominal wall vessels such as the inferior epigastric
vessels, or from large-caliber vessels found within the
adhesions.
Consequence
Signicant postoperative bleeding is very rare, with a
reported incidence of less than 2% of patients requiring
a blood transfusion.
Grade 1 complication
Repair
Abdominal wall bleeding can be controlled with direct
pressure and/or placement of sutures to ligate the
vessel. Larger-caliber vessels present in mature adhe-
sions or omentum are controlled with ultrasonic shears
or clips.
Prevention
The development of an avascular plane between the
adhesions and the peritoneum will prevent violation of
the dissection into the abdominal wall muscles. Trans-
illumination of the abdominal wall to visualize the
vessels before trocar placement and placement of xa-
tion sutures should be employed when possible. This
may not be possible when operating on an obese indi-
vidual. All adhesions should be examined for the pres-
ence of large-caliber vessels before lysing (Fig. 543).
 54 LAPAROSCOPIC INCISIONAL HERNIA REPAIR 539

A B

C D
Figure 542 A, In addition to the omental adhesions to the anterior abdominal wall, which can be taken down with blunt dissection, a
loop of small bowel is also clearly seen inside the fascial defect. This should be carefully cleared off of the peritoneum with sharp dissection
to prevent serosal injury. B, The majority of the adhesiolysis can be performed with sharp dissection without use of energy sources. An
avascular plane is developed between the peritoneum and the adhesions. C, As the adhesions are taken down close to the proximity of
small bowel, it is critical to visualize the tips of the scissors, as depicted in this photograph, in which a potential for injury is evident. The
use of ultrasonic shears would most denitely cause a thermal injury to the bowel wall. D, When there are a number of adhesions or
dense adhesions, it is safer to divide the hernia sac from the edge and reduce the contents with the peritoneum attached to the adhesions.
Normally, this is unnecessary and the hernia sac is left in situ.

Reduction of Hernia Contents serosal injuries. If the hernia contents cannot be

Intestinal Injury
In most cases, the hernia contents can be reduced without
much difculty. Excessive manipulation of incarcerated
bowel can result in a bowel injury.
Consequence
See the section on Lysis of Adhesions, earlier.
Grade 3/4 complication
Repair
See the section on Lysis of Adhesions, earlier.
Prevention
When bowel is incarcerated within a hernia defect, it is
important to avoid excessive tension to reduce the con-
tents. The use of atraumatic graspers will help avoid
reduced, external manual compression should be used.
In those patients in whom the previous two maneuvers
are not successful, sharp dissection is employed along
the fascial edges away from bowel wall to facilitate
reduction. A small incision can be made directly over
the hernia on the abdominal wall as well. This is par-
ticularly useful if a bowel injury is possible and the
bowel can be explored extracorporeally.
Mesh Selection and Preparation
Mesh Infection and/or Exposure
Consequence
Mesh infection accounts for over 40% of all adverse
events, as reported by the U.S. Food and Drug Admin-
istration.10 The resulting consequences of an infection
 540 SECTION VIII: HERNIA
Figure 543 Adjacent to the portion of bowel involved within
the adhesion, there is also a large-caliber vessel separate from the
mesentery. This vessel needs to be ligated before it is separated
for the abdominal wall to prevent hemorrhage that would obscure
dissection planes.
depend upon the source of infection, the degree of
infection, and the type of mesh placed for the repair.
Exposed mesh is considered to be contaminated and is
included in the same algorithm.
Grade 3/4/5 complication
Repair
If the source of the infection is a missed intestinal
injury, the patient will require a second operation.11,12
The injury needs to be explored and repaired, followed
by complete excision of the contaminated mesh. Recon-
struction of the abdominal wall can be performed with
a rectus abdominis myofascial advancement ap and/or
placement of bioabsorbable mesh.13 Mesh infection not
secondary to intestinal injury can be treated depending
on the type of mesh placed. Two broad categories of
mesh are those constructed with polypropylene or
expanded polytetrauoroethylene (ePTFE). Several
medium-sized studies described the advantages of the
former.1417 Polypropylene meshes can resist bacterial
colonization and have the ability to incorporate into
native tissue. This accounts for a higher likelihood of
salvaging the mesh with long-term antibiotics and/or
drainage of any associated abscess. However, if mesh
migration or stulas are present, mesh removal is
required. ePTFE meshes are not amenable to nonop-
erative modalities and require excision. Only one case
study, by Kercher, reported infected ePTFE mesh that
was able to be treated without excision.18
Prevention
The most important preventive measure is to maintain
strict sterile technique throughout the operation. The
surgical team has to be vigilant in not compromising
the surgical eld or contaminating the mesh before its
placement. Preoperatively, any remote sources of
infection, such as pneumonia, urinary tract infection,
or open skin lesions, should be addressed and resolved
before the operation. Although there has been some
debate in the literature on the use of intravenous anti-
biotics for hernia cases, the authors believe that this is
an important measure coinciding with the conclusions
from several randomized studies.1922 Lastly, despite the
lack of level-one evidence, the authors believe that the
use of adhesive surgical barriers to serve as physical
barriers against bacterial migration between the skin
and the mesh is important.
Enterocutaneous Fistula
Consequence
The reported incidence of enterocutaneous stulas is
less than 1% in large series and is described as isolated
case reports.23,24 Consequences include mesh infection,
intra-abdominal abscess, sepsis, and mortality.
Grade 3/4/5 complication
Repair
The management of intestinal stulas should follow
surgical principles in terms of patient resuscitation and
sepsis control. Eventually, the treatment also needs to
take into account the associated mesh infection. The
operation will include exploratory laparotomy, excision
of mesh, repair of stula, and closure of the abdominal
wall by options previously described (Fig. 544).
Prevention
In addition to the preventive measures previously
described for avoidance of intestinal injury, additional
surgical principles need to be adhered to. Any mesh
that does not have a specic composite layer on the
visceral surface to prevent adhesions should not be
placed in direct opposition to bowel. Certain mesh
types such as Marlex or exposed polypropylene are
known to be associated with a higher rate of adhesion
formation, which potentially may lead to mesh erosion
into the bowel and resultant stula.25,26
Mesh Fixation
Hernia Recurrence
Consequence
Hernia recurrence after laparoscopic repair is associated
with several factors: mean defect size, longer operat-
ing times, previous hernia repairs, morbid obesity,
and higher complication rate.8 Patients will present
with symptoms similar to their initial complaints of
abdominal pain, presence of bulge, and/or incarcera-
tion. Unlike the open procedure, the published recur-
rence rate of approximately 5% in the laparoscopic
cohort is much lower in long-term outcomes.27,28 Most
failures are secondary to technical causes and can be
prevented.
Grade 3/4 complication
 54 LAPAROSCOPIC INCISIONAL HERNIA REPAIR
Figure 544 At time of exploration, the point of erosion between
the mesh and the underlying small bowel is evident with visible
mucosa and leakage of bile-tinged contents into the surround-
ing tissues. The mesh is excised followed by a short-segment,
small bowel resection and alternative closure of the abdominal
wall. The use of permanent mesh in this setting is absolutely
contraindicated.
Repair
With symptomatic recurrences in surgical candidates,
a second laparoscopic attempt at hernia repair is war-
ranted. Additional placement of mesh with appropriate
xation sutures and surgical tacks will be required.
Prevention
Several important technical considerations can ensure
the lowest rate of failure. It is critical to be able to
visualize the entire abdominal wall and clearly identify
all of the fascial defects (Fig. 545). This ability to
detect multiple hernias is a signicant advantage over
the open approach and likely accounts for a lower
recurrence rate. After the fascial defects have been
assessed, the mesh must be sized appropriately to allow
for at least 3 cm of overlap. Although there are conict-
ing data regarding the use of xation sutures, the
authors as well as data from the largest series conrm
that this step should not be omitted.2931 Depending
on the quality of the fascia, these sutures should be
placed at least every 5 cm and serve as the primary
source of xation. Hernia tacks are used as secondary
xation points between these sutures. The type of mesh
placed may also have some impact on recurrence rates
as it relates to mesh shrinkage. An evaluation of specic
mesh types with regards to prosthetic shrinkage revealed
that ePTFE had statistically signicant more shrinkage
than other standard meshes.25
541
Figure 545 The typical Swiss-cheesetype appearance of fascial
defects along the entire length of a midline incision. Each fascial
defect if left unrecognized would ultimately lead to a recurrence
of the hernia repair. The mesh will be sized to account for all the
defects in greatest dimension.
Other Complications
Ileus
In patients who required extensive lysis of adhesions or
had large fascial defects, a postoperative ileus may result.
It is important not to advance the diet in these cases to
minimize abdominal distention and emesis. A nasogastric
tube may be required for decompression, even in the
absence of bowel resection. Unnecessary manipulation of
bowel is the only preventive measure.
Grade 1 complication
Seroma
A postoperative seroma will develop in approximately 10%
of patients11 and account for approximately 40% of all
complications.9 Most seromas are associated with large
hernia defects, with a resultant dead space between the
mesh and the overlying skin. They are usually asymptom-
atic and resolve without any intervention.32 A symptom-
atic or persistent seroma may need to be aspirated under
sterile technique. Appropriate mesh size and xation will
prevent excessive dead space and uid accumulation. The
use of abdominal binders has not been shown to reduce
the incidence or size of seroma formation.
Grade 1/2 complication
Suture Site Pain
In addition to incisional pain associated with trocar sites,
patients may also complain of pain at the transabdominal
suture xation sites, related to tissue or nerve entrapment.
In most patients, the pain will resolve with time and
can be treated with narcotics and/or nonsteroidal anti-
inammatory drugs. For severe or persistent pain, injec-
tion of local anesthetic may be necessary and is effective.33
Depending on the number of xation sutures utilized, a
 542 SECTION VIII: HERNIA
single suture may be removed if it corresponds directly
to the site of tenderness and the surgeon is condent
about the time interval for the mesh to fully incorporate
within the native abdominal wall.
Grade 1/2 complication
Mesh Migration into the Urinary Bladder
Several publications have described the migration of mesh
into the urinary bladder after laparoscopic inguinal hernia
repairs. One case report, in addition to the case Heniford
described in his large series, has been published about the
same complication after LVHR.8,34 The urinary bladder
stula was treated with reoperation without a denitive
cause of the stula. In repairing lower abdominal inci-
sional hernias, the surgeon has to be familiar with the
pelvic anatomy to avoid placing sutures or tacks in vital
structures. When the fascial defect extends to the supra-
pubic area, the peritoneum is divided and dissected to the
pubis where it, along with the bladder, can be displaced
posteriorly. This maneuver exposes Coopers ligament
bilaterally and allows for xation of the mesh inferiorly
without injury to the urinary bladder. The use of a three-
way Foley catheter is also recommended.
Grade 3/4 complication
Small Bowel Perforation Secondary to
Spiral Tacks
Spiral titanium tacks are routinely used in the repair of
abdominal wall hernias. Small bowel perforation due to a
protruding spiral tack is a very rare complication and is
described in a case report occurring 2 weeks postopera-
tively.35 Management of this complication is previously
described in the section on Intestinal Injury. The
surgeon should be certain that the tacker is perpendicular
to the abdominal wall so that the tack becomes properly
Figure 546 After the four-quadrant sutures have been secured,
spiral tacks are placed circumferentially. These 4-mm tacks should
be ush with the mesh and not protruding excessively where they
can hook the underlying bowel.
situated into the wall (Fig. 546). Any loose or fallen tacks
should be promptly removed.
Grade 3/4/5 complication
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1. Winslow ER, Fleshman JW, Birnbaum EH, et al. Wound
complications of laparoscopic versus open colectomy. Surg
Endosc 2002;16:14201425.
2. Luijendijk RW, Hop WC, van den Tol P, et al. A
comparison of suture repair with mesh repair for incisional
hernia. N Engl J Med 2000;343:392398.
3. Burger JW, Luijendijk RW, Hop WC, et al. Long-term
follow-up of a randomized controlled trial of suture versus
mesh repair of incisional hernia. Ann Surg 2004;240:578
585.
4. LeBlanc KA, Booth WV, Whitaker JM, et al. Laparoscopic
incisional and ventral herniorrhaphy in 100 patients. Am J
Surg 2000;180:193197.
5. Carbajo MA, Martin del Olmo JC, Blanco JI, et al.
Laparoscopic approach to incisional hernia. Surg Endosc
2003;17:118122.
6. Rosen M, Brody F, Ponsky J, et al. Recurrence after
laparoscopic ventral hernia repair: a ve-year experience.
Surg Endosc 2003;17:123128.
7. Ujiki MB, Weinberger J, Varghese TK, et al. One
hundred consecutive ventral hernia repairs. Am J Surg
2004;188:593597.
8. Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic
repair of ventral hernia: nine years experience with 850
consecutive hernias. Ann Surg 2003;238:391400.
9. Perrone JH, Soper NJ, Eagon JC, et al. Perioperative
outcomes and complications of laparoscopic ventral hernia
repair. Surgery 2005;138:708715.
10. Robinson TN, Clarke JH, Schoen J, et al. Major mesh-
related complications following hernia repair: events
reported to the Food and Drug Administration. Surg
Endosc 2005;19:15561560.
11. Berger D, Bientzle M, Muller A. Postoperative complica-
tions after laparoscopic incisional hernia repair. Incidence
and treatment. Surg Endosc 2002;16:17201723.
12. Wright BE, Niskanen BD, Peterson DJ, et al. Laparo-
scopic ventral hernia repair: are there comparative
advantages over traditional methods of repair? Am Surg
2002;68:291295.
13. Szczerba SR, Dumanian GA. Denitive surgical treatment
of infected or exposed ventral hernia mesh. Ann Surg
2003;237:437441.
14. Birolini C, Utiyama EM, Rodrigues AJ, et al. Elective
colonic operation and prosthetic repair of incisional
hernia: does contamination contraindicate abdominal wall
prosthetic use? J Am Coll Surg 2000;191:366372.
15. Bleichrodt RP, Malyar AW, de Vries Reilingh TS, et al.
The omentum-polypropylene sandwich technique: an
attractive method to repair large abdominal-wall defects in
the presence of contamination or infection. Hernia
2007;11:7174.
16. Alaedeen DI, Lipman J, Medalie D, et al. The single-
staged approach to the surgical management of abdominal
wall hernias in contaminated elds. Hernia 2007;11:41
45.
 54 LAPAROSCOPIC INCISIONAL HERNIA REPAIR
17. Kelly ME, Behrman SW. The safety and efcacy of
prosthetic hernia repair in clean-contaminated and
contaminated wounds. Am Surg 2002;68:524
528.
18. Kercher KW, Sing RF, Matthews BD, et al. Successful
salvage of infected PTFE mesh after ventral hernia repair.
Ostomy Wound Manage 2002;48:4042.
19. Rios A, Rodriguez JM, Munitiz V, et al. Antibiotic
prophylaxis in incisional hernia repair using prosthesis.
Hernia 2001;5:148152.
20. Yerdel MA, Akin EB, Dolalan S, et al. Effect of single-
dose prophylactic ampicillin and sulbactam on wound
infection after tension-free inguinal hernia repair with
polypropylene mesh: the randomized, double-blind,
prospective trial. Ann Surg 2001;233:2633.
21. Aufenacker TJ, van Geldere D, van Mesdag T, et al. The
role of antibiotic prophylaxis in prevention of wound
infection after Lichenstein open mesh repair of primary
inguinal hernia: a multicenter double-blind randomized
controlled trial. Ann Surg 2004;240:955960.
22. Perez AR, Roxas MF, Hilvano SS. A randomized, double-
blind, placebo-controlled trial to determine effectiveness
of antibiotic prophylaxis for tension-free mesh herniorrha-
phy. J Am Coll Surg 2005;200:393397.
23. Losanoff JE, Rochman BW, Jones JW. Enterocutaneous
stula: a late consequence of polypropylene mesh abdomi-
nal wall repair: case report and review of literature. Hernia
2002;6:144147.
24. Ott V, Groebli Y, Schneider R. Late intestinal stula
formation after incisional hernia using intraperitoneal
mesh. Hernia 2005;9:103104.
25. Harrell AG, Novitsky YW, Peindl RD, et al. Prospective
evaluation of adhesion formation and shrinkage of intra-
abdominal prosthetics in a rabbit model. Am Surg
2006;72:808813.
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26. Mahmoud uslu HY, Erkek AB, Cakmak A, et al. Incisional
hernia treatment with polypropylene graft: results of 10
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27. Pierce RA, Spitler JA, Frisella MM, et al. Pooled data
analysis of laparoscopic versus open ventral hernia repair:
14 years of patient data accrual. Surg Endosc 2007;21:
378386.
28. Lomanto D, Iyer SG, Shabir A, et al. Laparoscopic versus
open ventral hernia mesh repair: a prospective study. Surg
Endosc 2006;20:10301035.
29. vant Riet M, de Vos van Steenwijk PJ, Kleinrensink GJ,
et al. Tensile strength of mesh xation methods in
laparoscopic incisional hernia repair. Surg Endosc 2002;
16:17131716.
30. Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic
ventral and incisional hernia repair in 407 patients. J Am
Coll Surg 2000;190:645650.
31. LeBlanc KA, Booth WV, Whitaker JM, et al. Laparoscopic
incisional and ventral herniorraphy: our initial 100
patients. Hernia 2001;5:4145.
32. Susmallian S, Gewurtz G, Ezri T, et al. Seroma after
laparoscopic repair of hernia with PTFE patch: is it really a
complication? Hernia 2001;5:139141.
33. Carbonell AM, Harold KL, Mahmutovic A, et al. Local
injection for the treatment of suture site pain after
laparoscopic ventral hernia repair. Am Surg 2003;69:688
691.
34. Riaz AA, Ismail M, Barsam A, et al. Mesh erosion into the
bladder: a late complication of incisional hernia repair. A
case report and review of the literature. Hernia 2004;8:
158159.
35. Ladurner R, Mussack T. Small bowel perforation due to
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scopic incisional hernia repair. Surg Endosc 2004;18:
1001.
55
Component Separation for Complex
Abdominal Wall Reconstruction and
Recurrent Ventral Hernia Repair
Brian Reuben, MD, Daniel Vargo, MD,
and Marga F. Massey, MD
INTRODUCTION
Since the 1980s, signicant changes have occurred in the
operative management of the abdomen in patients requir-
ing large-volume resuscitation secondary to hemorrhagic
or septic shock. Damage control laparotomies with rapid
management of life-threatening conditions and temporary
wound closure are increasingly more common and designed
to avoid the dreaded triad of deathhypothermia, coagu-
lopathy, and hemorrhage. In addition, intra-abdominal
hypertension or abdominal compartment syndrome has
become a well-recognized entity that often mandates man-
agement of a complex abdominal wall hernia with signi-
cant loss of domain. With damage control laparotomies
and abdominal compartment syndrome, large abdominal
wall defects are the resultant surgical challenge.
A mesh-independent technique of abdominal wall
reconstruction was rst introduced in 1990 to address
large, complex abdominal wall hernias with either a prior
history of infection or a signicant loss of domain.1 This
autologous reconstruction method, commonly known as
component separation, has achieved widespread acceptance
for these types of problems before the introduction of the
acellular dermal regenerative tissue matrix AlloDerm
(LifeCell, Branchburg, NJ).2,3 Component separation, as
it was initially introduced, utilizes bilateral, innervated,
bipedicle, rectus abdominis muscle and fascial composite
aps transposed medially to reconstruct the central
abdominal wall. Several procedural variations have
appeared in the literature, all based on central mobiliza-
tion of the rectus abdominis muscle and associated overly-
ing fascia and a distinct independence from synthetic mesh
materials.38
All effective methods of abdominal wall reconstruction
address ve basic goals: (1) restoration of function and
integrity of the musculofascial abdominal wall; (2) preven-
tion of visceral eventration; (3) provision of dynamic
muscle support; (4) provision of a tension-free repair; and
(5) optimizing an aesthetically acceptable appearance.3,4,9
Immediate reconstruction of a large abdominal wall defect
is optimal. However, it may be suitable only in a medically
stable patient with a clean wound bed and reliable recon-
structive options that provide a tension-free closure. A
delayed approach potentially involving multiple, staged
surgical procedures is more common for the high-risk
patient with an unstable or contaminated wound and
multiple medical problems. Staged reconstructions com-
monly require the temporary use of absorbable mesh
materials and delayed split-thickness skin grafting followed
by a component separation procedure 6 to 12 months
later. These extreme cases may require combined tissue
expansion techniques to provide stable skin coverage over
the fascial repair. They may require mesh in addition to
a component separation procedure with the distinct goal
of re-creating the majority of the abdominal wall with a
tension-free predominance of innervated muscle aps,
which promote function (Fig. 551).
Component separation is ideal for midline defects with
fascial defects greater than 3 cm in transverse diameter.9
Bilateral component separation provides 8 to 10 cm of
mobilization in the epigastric area, 10 to 15 cm in the
midabdomen, and 6 to 8 cm in the suprapubic region.10
It is ideal for the high-risk, loss-of-domain patient who
has failed a synthetic mesh repair secondary to infection.
It is a signicant reconstructive option for patients with
stomas within the operative eld. It should be considered
superior and a rst line of reconstruction for patients who
have had prior irradiation, who have a bowel injury in the
setting of a laparoscopic hernia repair attempt, who have
suffered prior enterocutaneous stula, or who have risk
factors for wound healing problems that preclude the use
of synthetic mesh materials. Coordinated preoperative
evaluation by general and plastic surgeons with a focus on
abdominal wall reconstruction is effective in the comple-
tion of these difcult surgical procedures with acceptable
levels of morbidity and mortality.
 546 SECTION VIII: HERNIA

A1 A2

B1

A3
Figure 551 Staged abdominal wall reconstruction for abdominal compartment syndrome. A, A 56-year-old man with a history of
necrotizing pancreatitis and abdominal compartment syndrome presented for a near-total abdominal wall reconstruction. His reconstruc-
tion was delayed secondary to a multiple laparotomy requirement for pancreatic dbridement. Once he was medically stable, his open
abdominal wound was managed by Vicryl mesh placement followed by dressing changes and progression to a Wound V.A.C. A staged
split-thickness skin graft (STSG) was then placed at a second operative procedure. The patient had tissue expanders placed under his
abdominal skin aps to recruit skin for nal skin ap closure as well as expanders beneath bilateral tensor fascia lata (TFL) aps 12 months
after his initial presentation. These expanders were lled weekly in preparation for his nal reconstructive procedure.
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL 547

B2
C1

C2 C3
Figure 551, contd B, STSG and abdominal wall tissue expanders are removed at a delayed component separation procedure 15
months after his initial absorbable mesh placement. Bilateral backup expanded TFL aps were not required to achieve a nal closure.
C, The patient is shown at 27 months after his initial presentation, 12 months after his denitive repair with midline approximation of his
skin aps as facilitated by abdominal wall tissue expansion. His fascia was reconstructed by a component separation procedure in addition
to Prolene mesh, given the size of is fascial defect. Bilateral expanded TFL aps, designed to supplement his component separation, were
preserved, given an intraoperative nding of a 20-cm pancreatic pseudocyst requiring enteric diversion. It was believed that the patient
was at risk for revisional intra-abdominal surgery, given his pancreatic pathology. At 1 year, he has no evidence of hernia recurrence, with
a majority of his abdominal wound having been reconstructed by autologous, innervated rectus abdominis myocutaneous aps.
 548 SECTION VIII: HERNIA

INDICATIONS dehiscence, and the need for prolonged dressing

changes. Previous incisions should be used or extended
Large abdominal wall defect (>40 cm2)loss-of- when possible.9 Otherwise, the midline incision is rec-
domain ventral hernia ommended because it is the least damaging to neuro-
Epigastic (810 cm horizontal advancement vascular and functional structures.11
requirement) Grade 1/2/3 complication
Midabdominal (1015 cm horizontal advancement
requirement) Repair
Suprapubic (68 cm horizontal advancement Operative dbridement of necrotic skin should be fol-
requirement) lowed by the initiation of wet to dry dressing changes
Recurrence of hernia defect after prior primary closure three times daily. The wound should be inspected
attempt and contraindication for synthetic mesh routinely and repeat dbridements completed at the
Failed primary mesh hernia repair secondary to bedside when indicated. If the wound appears well at
infection 5 days, one may either return to the operating room
Bowel injury in setting of laparoscopic hernia repair for adipocutaneous ap readvancement and closure or
Exposed mesh with unstable surrounding skin initiate the placement of a wound V.A.C. (KCI, San
Presence of enterocutaneous stula or ostomy in oper- Antonio, TX) negative-pressure dressing with changes
ative eld every 3 days. Traditional dressing changes should con-
Prior abdominal wall irradiation tinue if there is any question of ongoing infection.
Systemically compromised patient Specically, V.A.C. therapy should not be used to
Concurrent malignancy control infected wounds.
Systemic immunosuppression secondary to organ
transplantation Prevention
Active human immunodeciency virus (HIV) Careful attention should be addressed toward previous
infection scars, surgical incisions, ostomy sites, and drain sites
Corticosteroid dependence because these may have disrupted the blood supply
Malnutrition from the intercostal arteries and may result in skin ap
Large body surface area burn ischemia and necrosis. Midline incisions are most
appropriate for thin patients. It is best to avoid trans-
verse and subcostal incisions, which can interrupt the
OPERATIVE STEPS supercial epigastric arcades and the segmental vessels
of the intercostal system.12
Step 1 Skin incision Morbidly obese patients with signicant hernias may
Step 2 Enter peritoneal cavity with excision of split- require a more sophisticated reconstructive plan. When
thickness skin graft (STSG) massive hernias are repaired for these patients, the depen-
Step 3 Develop adipocutaneous advancement aps dent pannus may be resected to promote wound healing.
Step 4 Excise poorly incorporated mesh It is best to approach these patients with a limited midline
Step 5 Excise hernia sac skin incision that is excised in its entirety with an inferior
Step 6 Lyse adhesions to an intraperitoneal level 4 cm adipocutaneous ap advancement and transverse closure.
lateral to fascial defect It is imperative not to place this nal transverse incision
Step 7 Vertical incision of external oblique fascia 1 cm at the juncture of the mons as in a traditional abdomino-
lateral to linea semilunaris plasty because it is associated with a high risk of infection
Step 8 Muscle ap advancement and approximation in obese patients. In addition, it limits revisional surgery
Step 9 Adipocutaneous ap advancement and in the context of wound dehiscence (Fig. 552).
approximation Extreme care must be extended to patients with prior
Step 10 Assimilation of postoperative secrets for ostomies. Skin bridges between midline incisions and the
success ostomy site are at high risk for ischemia. If the ostomy is
to remain, one should consider a unilateral component
separation procedure (Fig. 553). If intestinal reconstruc-
OPERATIVE PROCEDURE tion is a part of the operative intervention, one should
consider complete excision of the ostomy site including
Skin Incision the intervening skin bridge (Fig. 554). If not feasible,
typically in the thin patient, we recommend primary
Skin Necrosis and Dermal Dehiscence
closure of the ostomy site with expectant management.
Consequence Wound dehiscence at the previous ostomy site can be
The surgical incision must be carefully planned to treated with dressing changes and staged closure at 5 days
prevent unnecessary skin necrosis, skin ap dermal or wound V.A.C. management.
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL 549

A1 A2

A3
B
Figure 552 Surgical incision placement in the morbidly obese patient with a plan for panniculectomy to reduce postoperative wound
complications. A, Preoperative appearance of a 64-year-old man with a recurrent giant abdominal wall hernia with retained mesh, loss of
domain and prior midline incision. B, Intraoperative wound closure with an inferior adipocutaneous ap advancement. The initial explora-
tion was via a limited midline incision centered at the umbilicus. The access incision was completely excised with the advancement of an
inferior adipocutaneous ap and a transverse closure remote from the mons and the native inferior skin fold to avoid potential wound
infection.
 C1 C2

Figure 552, contd C, Postoperative appearance of skin ap

closure at 4 months with no evidence of adipocutaneous skin ap
C3
necrosis or dermal dehiscence.

A1 A2
Figure 553 Unilateral component separation for maintained ostomy in the operative eld. A, Intraoperative appearance of a 43-year-
old woman treated for ovarian cancer to include a total colectomy and end ileostomy complicated by multiple small bowel stulasto
composite mesh placed to treat a prior midline evisceration event.
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL 551

A3 A4

C
Figure 553, contd B, No component separation is performed on the ipsilateral side of the end ileostomy in order to preserve ostomy
function and to avoid possible parastomal hernia. C, Postoperative appearance at 6 months with no evidence of midline hernia and per-
sistent good stoma function.

Enter Peritoneal Cavity with Excision of STSG Repair

Iatrogenic Enterotomy
Consequence
Reentry into the peritoneal cavity of patients with
complex hernias with or without STSG can potentially
result in iatrogenic enterotomies with contamination of
the surgical eld. Such a complication can be limited
to wound cellulitis. In its most extreme form, the
patient may develop an enterocutaneous or enteroen-
teric stula heralded by possible intra-abdominal abscess
and sepsis.
Grade 1/2/3/4 complication
Simple oversewing of the enterotomy with running 3-
0 polydioxanone (PDS) suture is appropriate for minor
serosal injuries. More extensive devascularization inju-
ries should be approached with possible bowel resec-
tion using accepted stapling techniques.
Prevention
Timing of exploration and STSG excision can be
assessed on physical examination preoperatively. Typi-
cally, most patients are not ready for reoperation until
the STSG can be lifted from the underlying bowel.
Surgery should be delayed until this simple maneuver
 552 SECTION VIII: HERNIA

A1 A2

A3
B1
Figure 554 Adipocutanteous ap advancement and excision of prior colostomy site to promote wound healing. A, A 46-year-old
woman with a history of rectal injury in the setting of open hysterectomy requiring diverting colostomy and open wound care, resulting
in a midline hernia for repair. The patient has a prior Phanansteil incision concealed beneath her dependent pannus in addition to a right
subcostal incision secondary to an open cholecystectomy.
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL 553

B2 B3

Figure 554, contd B, A midline incision was used for her exploration, given the patients prior right subcostal incision as a contra-
indication for an immediate transverse skin ap closure. Her transverse colostomy site was completely excised with medial advancement
of her right-sided adipocutaneous ap to promote wound healing and improved abdominal wall contour.

injuries. Not all such injuries are preventable, particularly

in patients with prior synthetic mesh placement. Judicious
repair must be completed when injuries occur. We suggest
aggressive staged irrigation of the abdomen and skin aps
during closure overtop of closed suction drains in the
setting of iatrogenic bowel injuries.

Postoperative Ileus
Figure 555 Assessing time of elective hernia repair. Lifting the
STSG from the underlying bowel should be a pain-free assessment
in the clinic prior to elective hernia repair.
can be preformed in the clinic with minimal pain (Fig.
555). Patients without STSG should be delayed for a
minimum of 6 months after they have achieved a closed
wound.
Meticulous sharp dissection during adhesiolysis using
the surgical principles of traction and countertraction to
develop dissection planes between loops of bowel and the
abdominal fascia are necessary to prevent iatrogenic bowel
Consequence
A prolonged ileus is a common complication with a
reported incidence of 27%.13 Uncomplicated ileus is the
direct result of extensive enterolysis during the take-
down of the hernia. It can be secondary to electrolyte
abnormalities in patients having received a preoperative
bowel preparation. Of more clinical concern, it can be
an early sign of an intra-abdominal infectious process
or intestinal anastomotic leak.
Grade 1/2/3/4 complication
Repair
Potentially correctable sources for prolonged ileus
should be examined to include serum electrolytes, leu-
kocyte count, and urinary analysis. Fever, abdominal
pain, leukocytosis, and abdominal distention associated
with profound emesis should prompt consideration of
abdominal computed tomography (CT) scanning to
dene possible intra-abdominal uid collections and/
or abscess.
 554 SECTION VIII: HERNIA
Prevention
Patients are on nothing by mouth (NPO) with or
without a nasogastric tube until they demonstrate evi-
dence of bowel function. Ileus in an afebrile patient
with a normal leukocyte count, normal serum electro-
lytes, and uncontaminated urine can be managed
expectantly. Radiographic investigation should be con-
cordant with the clinical setting.
Develop Adipocutaneous Advancement Flaps
Ischemia and/or Venous Congestion
Consequence
Adipocutaneous ap ischemia and/or venous conges-
tion can lead to partial or full-thickness necrosis and
an open wound with its associated problems of
caloric consumption, risk for infection and potential for
fascial dehiscence/evisceration, and extended nancial
requirements of dressing supplies and continued
surveillance.
Grade 1/2/3 complication
Repair
Threatened adipocutaneous aps require expectant
management. Serial physical examinations with an
experienced eye will facilitate the timing of surgical
dbridement. Initial steps to prevent progression of
ischemia and venous congestion include bedside release
of the skin closure sutures and edema control. Persis-
tent tension on ap closure can result in progression of
necrosis. Early release of tension is a preventive measure.
Timely dbridement and ap readvancement after the
diuresis of third-space uids may alleviate this problem.
Incomplete wound closure can be addressed with dress-
ing changes or wound V.A.C. placement.
Prevention
Adipocutaneous aps should be elevated at the junc-
ture of the anterior fascia, with minimal fat being
left behind on the fascia. The technical focus is ap
development using low-setting cautery and precise
control of the perforators extending through the fascia.
Distinct coagulation or clip and/or suture ligature
of these perforators is necessary in order to prevent
thermal injury down into the pedicle vessels supplying
the underlying muscles or up into the adipocutaneous
ap. Precise use of the cautery is imperative to prevent
areas of fat necrosis within the ap. In addition, it
is important to protect adipocutaneous aps from
traction, avulsion, and compression injury by surgical
assistants.
Some patients may require a signicant uid resuscita-
tion secondary to a prolonged operative course in the
setting of concomitant secondary procedures. Tissue edema
may become problematic, particularly in patients with mul-
tiple prior skin incisions. Intraoperative use of colloid over
crystalloid has been advantageous.14,15 Delaying the skin
ap closure or purposefully leaving marginal skin in place
for 5 days is advised. Return to the operating room after a
physiologic postoperative diuresis and skin ap margin-
ation is the sign of a thoughtful surgeon. All patients
should be counseled preoperatively of this possible
staging of their abdominal wall closure (Fig. 556).
Excise Poorly Incorporated, Previously
Placed Mesh
Infection and Recurrent Hernia
Consequence
Lack of mesh incorporation into surrounding tissues
is consistent with a clinical diagnosis of chronic infec-
tion. Retained, poorly incorporated mesh may lead to
persistent wound infection. Retained mesh with areas of
suture line dehiscence from the fascia can lead to hernia
recurrence and need for unplanned reoperation.
Grade 2/3 complication
Repair
Retained infected mesh and missed suture line dehis-
cence from prior hernia repairs will necessitate redo
exploration and secondary hernia repair.
Prevention
Intraoperative examination of previously placed mesh
as a distinct step in the operative procedure is impera-
tive. Aggressive dbridement with care to preserve the
vascular supply to the remaining abdominal wall is pref-
erable over leaving chronically infected mesh or small
suture-line hernias clinically not apparent preopera-
tively on physical examination.
Excise Hernia Sac
Seroma and Possible Infection
Consequence
Retained hernia sac may lead to postoperative seroma.
Devascularized retained hernia sac will result in wound
infection and possible dehiscence and evisceration.
Complete excision of the hernia sac will eliminate these
complications and facilitate ease to a technically com-
petent fascial closure.
Grade 2/3 complication
Repair
Suprafascial seromas secondary to retained viable hernia
sac can be treated expectantly with aggressive use of
closed bulb suction drains that remain in situ until
drain output is less than 30 ml/day per drain. Ultra-
sound-guided percutaneous drain placement is an
acceptable approach to early postoperative seroma
formation. Persistent drain output from a percutaneous
drain or recurrence after 3 weeks is suggestive of the
formation of a seroma capsule, which requires a surgi-
cal excision and reclosure.
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL 555

A1 A2

B1

A3
Figure 556 Staging of adipocutaneous ap closure. A, A 64-year-old man with history of bladder extrophy presents with a recurrent
hernia secondary to infected synthetic mesh in the setting of bilateral paramedian abdominal incisions and a right-sided sigmoidureterostomy.
B, The patient was explored through a left paramedian incision with removal of a staged superior tissue expander. His fascial reconstruc-
tion was completed by the use of acelluar dermal matrix. Adipocutaneous aps were allowed to marginate for 4 days prior to return to
the operating room for ischemic ap excision and staged closure.
 556 SECTION VIII: HERNIA

B2 B3

C1 C2
Figure 556, contd C, The patients postoperative appearance at the time of Jackson-Pratt drain removal.

Infection secondary to retained nonviable hernia
sac requires dbridement and open management of
the wound with a staged, secondary abdominal wall
reconstruction.
Prevention
Precise excision of the hernia sac is the best prevention.
Occasionally, we have used well-vascularized hernia sac
atop of synthetic mesh in the setting of threatened skin
aps (Fig. 557). If synthetic mesh or acellular dermis
is used in combination with a component separation
beneath thin adipocutaneous aps with overlying hernia
sac, one must use multiple closed suction drains, which
receive aggressive stripping and perioperative surveil-
lance. If the adipocutaneous aps are lost, a portion of
the hernia sac may protect the underlying mesh or
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL 557

AlloDerm against infection until an STSG can be

applied in a staged fashion.

Complete Lysis of Adhesions to an

Intraperitoneal Level 4 cm Lateral to
the Fascial Defect
Bowel Injury
Consequence
Small or large bowel adherent to the undersurface of
the abdominal wall in near proximity to the hernia sac
may inadvertently be injured or included in the suture
used to reapproximate the fascia.
Grade 3/4 complication
Repair
Unrecognized iatrogenic injury to or inclusion of the
bowel within the fascial closure will require reoperation
for an intra-abdominal catastrophe heralded by abdom-
inal sepsis and possible dehiscence or evisceration. This
too leads to open wound management followed by a
staged, secondary reconstruction.
C3
Prevention
Figure 556, contd. Surgeons of all ages and degrees of experience should
maintain a level of attentiveness to prevent the inadver-
tent inclusion of a loop of bowel within the suture line
of a fascial closure. Lysis of adhesions to a 4-cm margin
will facilitate the ease of fascia reapproximation.

A1 A2
Figure 557 Use of preserved, well-vascularized hernia sac beneath thin adipocutaneous aps. A, A 64-year-old man presents for
abdominal wall reconstruction for recurrent failed infected mesh. Comorbidities included obesity, diabetes mellitus, and congestive heart
failure.
 558 SECTION VIII: HERNIA

A3 B1

B2
B3
Figure 557, contd B, Hernia sac was preserved for use overtop of an acellular dermal matrix repair, given the anticipated thin nature
of his skin aps.
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL 559

Vertical Incision of External Oblique Fascia
1 cm Lateral to the Semilunaris
Spigelian Hernia
Consequence
Dissection deep to the external oblique muscle can
injure the internal oblique fascia or muscle, resulting
in a defect similar to a spigelian hernia. This injury
results in loss of fascial continuity and dynamic support
with loss of intra-abdominal domain relative to the
chronicity of a failure to diagnose or treat this unusual
defect.
Grade 3/4 complication
Repair
If unintended injury to the underlying internal oblique
fascia occurs, interrupted reinforcing stitches may be
placed. Typically, the internal oblique fascia is friable
and a braided Vicryl suture is best, although leaving
one with a high risk of remote hernia formation. If the
resulting defect or weakness is large, a piece of synthetic
mesh may be placed to reinforce the area using an onlay
technique, again noting a risk for hernia recurrence.
Frank rupture of the transverse abdominal muscle after
inadvertent transection of both the external and the
internal oblique muscle layers has been reported
in the literature with repair using onlay polypropylene
mesh.16
AlloDerm should be considered in patients with a risk
of infection. Intra-abdominal acellular dermal matrix or
mesh placement can be completed using modied tech-
niques of laparoscopic hernia repair, namely, transfascial
lateral permanent suture placement and the use of efcient
hernia tackers (Salute Fixation System, Davol, Inc.,
Cranston, RI) (Fig. 558).
Prevention
Meticulous dissection and observation of proper ana-
tomic landmarks are imperative. The linea semilunaris
is noted by the insertion of the external oblique fascia
at the lateral rectus abdominis border. The initial lon-
gitudinal incision should be placed 1 cm lateral to the
linea semilunaris. Generally, the fascial planes are quite
distinct and allow for easy dissection. The plane between
the external and the internal oblique may be opened
out to the posterior axillary line. However, the mobil-
ity of the innervated rectus abdominisinternal oblique
transversus abdominis muscle complex should routinely

A B

Figure 558 Intra-abdominal acellular dermal matrix placement

for lateral fascial weakness secondary to internal oblique injury.
A, A 54-year-old woman presented with a lateral abdominal wall
hernia secondary to an avulsion injury in the setting of a motor
vehicle accident. Her oblique muscles were avulsed from the right
rectus abdominis muscle, and a delayed reconstruction included
Vicryl mesh placement followed by AlloDerm, utilizing an open inlay
technique. B, Percutaneous transfascial xation sutures were used
for lateral AlloDerm advancement in the manner they would be
applied in the setting of a laparoscopic hernia repair. C, Salute lapa-
roscopic hernia clips were then applied to reduce postoperative pain
C
and surgical time.
 560 SECTION VIII: HERNIA
be evaluated to prevent excessive dissection laterally,
therefore decreasing the chances for an accidental deep
fascial injury. The typical component separation release
separates the external oblique muscle and aponeurosis
from its connection to the anterior rectus fascia from
the costal margin to the iliac crest at a level just lateral
to the linea semilunaris. The external oblique can then
be separated off the internal oblique with blunt dissec-
tion, avoiding injury to the internal oblique fascia and
allowing the muscles to slide relative to one other (Fig.
559).
Denervation of Rectus Abdominis Muscle
Consequence
Dissection deep to the internal oblique muscle may
cause denervation of the rectus abdominis muscle and
resulting atrophy and pseudohernia or the appear-
ance of an eventration. Nerve injury such as this theo-
retically can also result in neuromas and chronic pain
syndromes.
Grade 2/3/4 complication
Repair
Intercostal nerve transection can be repaired with inter-
rupted 9-0 nylon suture using microscopic magnica-
tion. Often, these injuries are of a traction/avulsion-type
injury and respond poorly to repair. One should seek
assistance from a consulting surgeon experienced in
nerve repairs.
A1
Figure 559 Component separation surgical procedure. A, A 23-year-old woman with ovarian cancer presented with midline incision
hernia for autologous repair. Risk factors for hernia recurrence included body mass index (BMI) greater than 30, active malignancy, and
dependent pannus.
Prevention
Finding the proper plane of dissection is crucial to
avoid this potential complication. The surgical dissec-
tion plane is between the external and the internal
obliques and is avascular. Excessive bleeding should
prompt a higher level of attention to this potential
complication. The intercostal nerves supplying the
rectus abdominis run deep to the fascia of the internal
oblique muscle lateral to the linea semilunaris.
Muscle Flap Advancement and Approximation
Failure to Obtain Closure
Consequence
Not all hernias can be repaired by a component separa-
tion procedure. Fascial defects may be underestimated
on physical examination by the operative surgeon. Flap
advancements may fail to approach reported ranges.
Lack of a concerted surgical plan can result in an acute
failure to close the fascial defect. Skin ap closure over
this type of a remaining fascial defect results in an
immediate hernia and risk for skin ap necrosis and
dehiscence and/or evisceration. Unstable or insuf-
cient skin for closure results in a full-thickness open
wound requiring staged reconstructive operative inter-
ventions. This last situation would likely result in a
Vicryl meshbased reconstruction in most centers (see
Fig. 551). As is shown, expanded bilateral tensor
fascia lata (TFL) aps were designed as a backup plan
A2
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL 561

A3 B1

B2 C
Figure 559, contd B, The hernia sac has been completely excised, leaving a 6-cm midline fascial defect for repair. Methylene blue
has been applied, outlining the linea semilunaris bilaterally. The umbilical stalk has been preserved with circumferential incision. C, The
external oblique fascia is incised 1 cm lateral to the linea semilunaris (inked in blue) from the costal margin inferiorly to the iliac crest. The
internal oblique is viewed dorsally within the component separation.

for reconstruction, should component separation have
failed to provide a tension-free fascial closure.
Grade 3/4 complication
Repair
Backup, or salvage, reconstructive options should be
outlined preoperatively for the surgical team and for
informed consent of the patient. Synthetic mesh hernia
reconstruction can be used in combination with a
component separation procedure. For patients at risk
for or with active infection, we have used rotational
TFL ap reconstructions (Figs. 5510 and 5511).
More recently, we have converted to AlloDerm cadav-
eric acellular regenerative tissue matrix, given its ease
of acquisition and elimination of the donor site (Fig.
5512). Long-term recurrent hernia rates utilizing
acellular dermis are currently unavailable. Giant hernias
repaired with acellular dermal matrices may display
increased abdominal girth over time without a discrete
hernia, necessitating excision of a midportion of the
matrix to restore a functionally acceptable result.
AlloDerm can have retained antibiotics, which may
 562 SECTION VIII: HERNIA

D1 D2

F1
Figure 559, contd D, The right-sided component separation is advanced to the midline and closed with running Prolene suture. The
umbilicus is preserved at the midline. E, A superior-based adipocutaneous ap is advanced to the level of the mons for total excision of
the dependent pannus to promote wound healing and function. This technique does require the creation of a full-thickness defect for
umbilical reconstruction. Drains exit the lateral aspect of the incision to prevent additional drain site exit wounds. F, Postoperative appear-
ance of right-sided component separation independent of synthetic mesh, with superior adipocutaneous ap advancement and closure
resulting in a functional and esthetically pleasing result.

precipitate allergic reactions. We encourage careful
review of the manufacturers product insert.
Supplementary surgical techniques have been described
to gain additional fascial advancement to the traditional
component separation procedure. If there is inadequate
coverage over the xiphoid and subxiphoid region with
excessive tension on the closure, removal of the xiphoid
process, excision of any neo-ossications in the upper
wound, or taking the external oblique fascia up on the
costal margin 6 to 8 cm can provide some additional
mobility of the upper fascia.10 Release of the posterior
rectus sheath 1.0 to 1.5 cm from the linea alba has been
described in the literature in order to gain additional
advancement of composite tissue aps.1,17 This maneuver
can result in injury to the neurovascular pedicle to the
rectus abdominis muscle. Such a vascular injury could
result in partial or total ap loss. Partial ischemia of the
muscle ap can lead to atrophy, at best, presenting with
pseudohernia or eventration. Total ap loss results in
hernia recurrence requiring immediate revision. Failure to
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL
F2
Figure 559, contd.
diagnose total muscle ap necrosis can lead to signicant
soft tissue infection and a more complex staged recon-
struction. Given the risk of total ap loss in the hands of
the inexperienced surgeon, we discourage this supplemen-
tal aspect of component separation procedures. Other
partition methods are considered at high risk for such
a complication and should be avoided (Fig. 5513).6
Prevention
Careful preoperative planning can prevent an unex-
pected failure of fascial closure. Abdominal CT scan-
ning can dene fascial boundaries in morbidly obese
patients. Interdisciplinary teams including general and
plastic surgeons dedicated to complex abdominal wall
reconstruction can foster an environment to address
the more difcult cases hallmarked by prior resistant
soft tissue infections, radiation, profound loss of
domain, and in particular, unstable skin.18
An additional approach to aid in obtaining closure,
although invasive and requiring several weeks to perform,
is the placement of inatable tissue expanders between
the external and the internal oblique muscles, parallel
to the abdominal wall defect, to expand the lateral abdom-
inal wall.7,8 Tissue expanders are inated gradually, allow-
ing for an expansion of the abdominal domain and
possible closure of larger defects (see Fig. 551). The
use of vacuum-assisted devices to help achieve early fascial
closure is a promising new advance that may help facilitate
closure of the fascia or aid in overall management of
large abdominal wounds, although more experience is
needed.19,20
563
F3
Recurrent Hernia, Dehiscence, Evisceration
Consequence
The rate of recurrent incisional hernia after component
separation closure of the abdominal wall defect varies
between 0% and 32%, with most studies having recur-
rence rates in the range of 2% to 12%.1,3,16,2123 Rates
of acute dehiscence and/or evisceration have been
reported as high as 43%.13
Grade 3/4 complication
Repair
Acute dehiscence/evisceration and recurrent hernia in
the setting of prior component separation often require
the addition of synthetic mesh, acellular dermis, or
more complex rotational autologous aps in the setting
of a secondary reconstructive operation (see Figs. 55
10 to 5512).
Prevention
Dehiscence, evisceration, and hernia recurrence occurs
more frequently in the morbidly obese population
(mean body mass index [BMI] >30 kg/m2).16,24 Some
consideration of weight loss prior to hernia surgery
should be discussed with all overweight patients. Com-
bined panniculectomy procedures may be benecial to
patients with more urgent surgical requirements (see
Fig. 559).
Prevention of excessive tension on the fascial closure
by placement of either synthetic mesh or AlloDerm at
the initial repair can reduce complication rates such as
these. The difculty lies in the common desire to avoid
 564 SECTION VIII: HERNIA

B1

A B2

B3 B4
Figure 5510 Rotational TFL ap for rectus abdominis resection and irradiation for sarcoma. A, A 26-year-old woman presents with
a midline abdominal wound secondary to a sarcoma resection and postoperative irradiation. A portion of her right rectus abdominis muscle
and overlying fascia was previously resected. B, A right TFL ap was used as an autologous method of reconstruction, given her history
of irradiation and chronicity of her open wound.
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL 565

P1 P2

P3 P4

Figure 5511 Abdominal wall reconstruction with TFL rotational

ap in an infected eld and history of failed synthetic mesh. A 56-
year-old man presents with infected Surgisis (COOK Biotech Inc.,
Indianapolis, IN) placed for an acute wound dehiscence in the setting
of an intraperitoneal cadaveric renal transplant. An ipsilateral TFL ap
is utilized for an immediate autologous reconstruction with complete
P5
removal of the infected synthetic mesh.

synthetic materials in many patients requiring component
separation. This desire to avoid mesh materials and
lengthy autologous ap reconstructions in these high-risk
patients subjects them to tight wound closures that places
them further at risk for dehiscence and recurrence. A
subtotal autologous reconstruction including a compo-
nent separation and acellular dermis with minimal tension
fares better for an obese patient with signicant loss of
domain over a component separation closed under undue
tension.
Some attention should be focused on the techniques of
ap approximation. A recent meta-analysis looking at
suture material and type of stitch for closure of abdominal
hernias suggests that the use of a nonabsorbable suture in
a running fashion may reduce the relative risk of incisional
hernia by up to 32%.25
 566 SECTION VIII: HERNIA

Figure 5512 Alternative method of reconstruction for failed
component separation. AlloDerm acellular dermal regenerative
tissue matrix is used for a recurrent hernia repair for a failed com-
ponent separation. The need for a multiple-sheet quilting tech-
nique places the patient at risk for hernia recurrence.
Respiratory Insufciency
Consequence
The loss-of-domain phenomenon can cause decreased
total lung capacity, vital capacity, and functional resid-
ual capacity. This may be evidenced by difculty with
ventilation.3 Loss of domain causing respiratory insuf-
ciency is likely the cause for an average stay of 2.7 days
in a surgical intensive care unit.13
Grade 3/4/5 complication
Repair
If respiratory insufciency or difculty ventilating the
patient is noted intraoperatively, the tension from the
closure can be released by taking down the midline
fascial repair and interposing synthetic mesh or Allo-
Derm. This will increase the intra-abdominal volume
and should resolve any acute surgically induced respira-
tory insufciency.
Prevention
Preoperative pulmonary function testing may be indi-
cated to identify patients at risk for the respiratory

A
Transverse abdominis fascia
External oblique fascia

RA

EO

IO
TA

Partitioning method

B
Figure 5513 Additional component separation fascial partition method. A, Hernia defect and abdominal wall anatomy superior to the
umbilicus after elevation of bilateral adipocutaneous aps. B, Component separation with addition of partition method. See text for full
description and technical warning.
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL
failure secondary to the loss-of-domain phenomenon.9
Patients should be screened for preexisting pulmonary
insufciency. Intraoperative observation of peak airway
pressures should be routine throughout the surgical
procedure. Aggressive pulmonary toilet postoperatively
is mandatory in this population of patients to prevent
perioperative pneumonia. Attention to alternative pain
management protocols may be required for more
complex hernia repairs to aid in early ambulation and
pulmonary toilet.
Adipocutaneous Flap Advancement
and Approximation
Seroma, Hematoma
Consequence
Fluid collections in between the fascia and the overly-
ing adipocutaneous aps place patients at risk for super-
infection, skin ap dehiscence, and prolonged wound
healing problems.
Grade 1/2/3 complication
Repair
Watchful waiting, needle aspiration, percutaneous drain
placement, or reoperation are all options, depending
on the clinical situation.
Prevention
Strategic closed suction wound drain placement intra-
operatively in combination with meticulous adipocuta-
neous ap planning and development is the key to
prevention of seroma formation. Drains must be cleared
of occlusive exudates by stripping the drains every 4
hours for conventional component separation proce-
dures and every 2 hours for those reconstructions
including AlloDerm. The exudate from wounds con-
taining AlloDerm are more viscous, the etiology of
which is currently unknown. Drains are kept in place
for up to 21 days for AlloDerm-independent recon-
structions, with shorter durations for AlloDerm recon-
structions in the range of 10 to 14 days. Drains are
removed when outputs are less than 30 ml/day per
drain. Prophylactic antibiotics for wound drains are
controversial, but this is a common practice in our
patients not requiring a preoperative bowel prepara-
tion. Subjectively, we have observed higher rates of
Clostridium difcile colitis in patients who have received
a bowel preparation and are maintained on postopera-
tive prophylactic antibiotics. This association is cur-
rently under investigation at our institution. We look
forward to the potential use of antibiotic-coated closed
suction drains currently under development in order to
alleviate the need for oral antibiotics (Bacterin Interna-
tional, Belgrade, MT).
Closed suction drains do not prevent hematomas. Given
the risk of deep vein thrombosis (DVT) and pulmonary
embolism (PE) in obese patients undergoing hernia repair,
567
all patients are aggressively treated with subcutaneous
heparin or enoxaparin.26,27 Care should be taken to alert
the nursing staff not to inject anticoagulants into the
abdominal adipocutaneous aps to avoid a local effect
predisposing a patient to a focal bleed. Acute resolution
of drain output should alert one to the possibility of a
compressive hematoma preventing uid egress. Ultra-
sound can be a helpful diagnostic tool in the obese
patient.
Wound Infection
Consequence
Supercial wound infections and focal incisional dehis-
cence can reect poor surgical technique or lack of
adherence to best practices.
Grade 1/2 complication
Repair
Bedside dbridement and local wound care typically
result in the resolution of simple wound healing
problems.
Prevention
Preoperative intravenous antibiotics are administered
to all patients at least 30 minutes prior to incision.
Maintaining standard principles of surgical sterility
yields comparable infection rates according to the surgi-
cal contamination grade. Adipocutaneous ap develop-
ment should reect as limited a dissection as possible in
an attempt to prevent ischemia and to promote a lower
rate of wound infection. Smoking should be eliminated
preoperatively, if at all possible.28 Interrupted dermal
monolament sutures (e.g., 3-0 Monocryl [Ethicon,
Inc., Cornelia, GA]) followed by running subcuticular
monolament suture (e.g., 4-0 Monocryl) are used
whenever possible. Deep sutures within the fat and
surgical staples are avoided. We further reenforce our
closures with DERMABOND (Ethicon, Inc., Cornelia,
GA) as a barrier method to ght infection. Use of
DERMABOND avoids the use of tape on delicate skin
aps, thereby avoiding tension bullae formation. In
addition, it promotes early showering to keep skin bac-
terial counts low.
Assimilation of Postoperative Secrets to Success
Skin Flap Bullae and Partial-Thickness Loss
Consequence
Use of abdominal binders and tape is discouraged
owing to the potential for injury to skin aps.
Grade 1/2 complication
Repair
Shear and/or tension bullae and partial-thickness skin
loss requires serial dbridement and local dressing
changes. It is important to provide a moist environ-
 568 SECTION VIII: HERNIA
ment to promote rapid healing should they occur.
Antibiotic ointments covered by nonadherent dressings
occasionally result in allergic reactions. Duoderm
(ConvaTec, Ltd., Deeside, UK) semipermeable hydro-
colloid dressing is an acceptable alternative.
Prevention
Once skin ap ischemia is no longer a concern, liposuc-
tion garments are preferred for abdominal wall com-
pression owing to their inherent design to protect
the skin (zippers, labels, and seams on the outside of
the garment). Compressive liposuction garments may
prevent seroma formation and should be encouraged
for 3 to 6 months postoperatively. Liposuction gar-
ments can hold absorbent dressings in place without
tape, should they be required. They are adequate in
holding dressings over open wounds should extended
would care be required. Many patients are more com-
fortable in some form of compression garment, there-
fore facilitating early ambulation.
DVT, PE
Consequence
Many hernia repair patients are at risk for perioperative
venous thromboembolic complications. Risk factors
include patient age, duration of general anesthetic,
concomitant acute trauma or active malignancy, and
elevated BMI.27
Grade 1/2/3/4 complication
Repair
Systemic anticoagulation with heparin or enoxapa-
rin and potential for inferior vena cava lter place-
ment according to accepted practice guidelines are
recommended.27
Prevention
Patients participate in an active postoperative ambula-
tion protocol. Our patients walk in the hallway on the
evening of surgery and seven times daily thereafter.
They record their walking on a chart, which they sub-
sequently use at home after discharge. Each walking
chart is reviewed with the patient on their rst postop-
erative visit to ensure continued ambulation and DVT/
PE prevention. Elastic compressive stockings, sequen-
tial compressive devices, and perioperative subcutane-
ous heparin or enoxaparin are aggressively applied.29
Consideration of home prophylaxis is important for
patients with active malignancies, obesity, or conditions
that predispose them to inactivity.29
CONCLUSIONS
Component separation is a useful surgical technique to
address the repair of complex abdominal wall hernias.
Used alone or in combination with other ancillary tech-
niques, it promotes maximal innervated musculofascial
coverage of the abdominal wall and improved function
for the individual patient. Complications can be avoided
by appropriate preoperative planning, familiarity of the
essential abdominal wall anatomy, meticulous surgical
technique, and attentive postoperative surveillance of the
surgical wound.
REFERENCES
1. Ramirez OM, Ruas E, Dellon AL. Components separa-
tion method for closure of abdominal-wall defects: an
anatomic and clinical study. Plast Reconstr Surg
1990;86:519526.
2. Kolker AR, Brown DJ, Redstone JS, et al. Multilayer
reconstruction of abdominal wall defects with acellular
dermal allograft (AlloDerm) and component separation.
Ann Plast Surg 2005;55:3641.
3. Shestak KC, Edington HJ, Johnson RR. The separation of
anatomic components technique for the reconstruction of
massive midline abdominal wall defects: anatomy, surgical
technique, applications, and limitations revisited. Plast
Reconstr Surg 2000;105:731738.
4. DiBello JN Jr, Moore JH Jr. Sliding myofascial ap of the
rectus abdominus muscles for the closure of recurrent
ventral hernias. Plast Reconstr Surg 1996;98:464
469.
5. Ennis LS, Young JS, Gampper TJ, Drake DB. The open-
book variation of component separation for repair of
massive midline abdominal wall hernia. Am Surg 2003;69:
733742.
6. Lindsey JT. Abdominal wall partitioning (the accordion
effect) for reconstruction of major defects: a retrospective
review of 10 patients. Plast Reconstr Surg 2003;112:477
485.
7. Jacobsen WM, Petty PM, Bite U, Johnson CH. Massive
abdominal-wall hernia reconstruction with expanded exter-
nal/internal oblique and transversalis musculofascia. Plast
Reconstr Surg 1997;100:326335.
8. Hobar PC, Rohrich RJ, Byrd HS. Abdominal-wall
reconstruction with expanded musculofascial tissue in
posttraumatic defect. Plast Reconstr Surg 1994;94:379
383.
9. Rohrich RJ, Lowe JB, Hackney FL, et al. An algorithm
for abdominal wall reconstruction. Plast Reconstr Surg
2000;105:202216.
10. Jernigan TW, Fabian TC, Croce MA, et al. Staged
management of giant abdominal wall defects: acute and
long-term results. Ann Surg 2003;238:349355.
11. Core GB, Grotting JC. Reoperative surgery of the
abdominal wall. In Grotting J (ed). Aesthetic and
Reconstructive Plastic Surgery. St. Louis: Quality Medical,
1995; pp 13271375.
12. Hurwitz DJ, Hollins RR. Reconstruction of the abdomi-
nal wall and groin. In Cohen M (ed): Mastery of Plastic
and Reconstructive Surgery. Boston: Little, Brown, 1994;
pp 13491359.
13. Lowe JB 3rd, Lowe JB, Baty JD, Garza JR. Risks
associated with components separation for closure of
complex abdominal wall defects. Plast Reconstr Surg
2003;111:12761283.
 55 COMPONENT SEPARATION FOR COMPLEX ABDOMINAL WALL
14. Sigurdsson GH. Perioperative uid management in
microvascular surgery. J Reconstr Microsurg 1995;11:57
65.
15. Joshi GP. Intraoperative uid restriction improves
outcome after major elective gastrointestinal surgery.
Anesth Analg 2005;101:601605.
16. de Vries Reilingh TS, van Goor H, Rosman C, et al.
Components separation technique for the repair of
large abdominal wall hernias. J Am Coll Surg 2003;196:
3237.
17. Losanoff JE, Richman BW, Jones JW. Endoscopically
assisted component separation method for abdominal
wall reconstruction. J Am Coll Surg 2002;194:388390.
18. Mathes SJ, Steinwald PM, Foster RD, et al. Complex
abdominal wall reconstruction: a comparison of ap and
mesh closure. Ann Surg 2000;232:586596.
19. Suliburk JW, Ware DN, Balogh Z, et al. Vacuum-assisted
wound closure achieves early fascial closure of open
abdomens after severe trauma. J Trauma 2003;55:1155
1160; discussion 11601161.
20. Miller PR, Meredith JW, Johnson JC, Chang MC.
Prospective evaluation of vacuum-assisted fascial closure
after open abdomen: planned ventral hernia rate is
substantially reduced. Ann Surg 2004;239:608614.
21. Saulis AS, Dumanian GA. Periumbilical rectus abdominis
perforator preservation signicantly reduces supercial
wound complications in separation of parts hernia
repairs. Plast Reconstr Surg 2002;109:22752280.
569
22. van Geffen HJ, Simmermacher RK, van Vroonhoven TJ,
van der Werken C. Surgical treatment of large contami-
nated abdominal wall defects. J Am Coll Surg 2005;201:
206212.
23. Lowe JB, Garza JR, Bowman JL, et al. Endoscopically
assisted components separation for closure of abdominal
wall defects. Plast Reconstr Surg 2000;105:720729.
24. Langer C, Schaper A, Liersch T, et al. Prognosis factors in
incisional hernia surgery: 25 years of experience. Hernia
2005;9:1621.
25. Hodgson NCF, Malthaner RA, Ostbye T. The search for
an ideal method of abdominal fascial closure: a meta-
analysis. Ann Surg 2000;231:436442.
26. Prystowsky JB, Morasch MD, Eskandari MK, et al.
Prospective analysis of the incidence of deep venous
thrombosis in bariatric surgery patients. Surgery 2005;
138:759763.
27. Buller HR, Agnelli G, Hull RD, et al. Antithrombotic
therapy for venous thromboembolic disease: the Seventh
ACCP Conference on Antithrombotic and Thrombolytic
Therapy. Chest 2004;126(3 suppl):401S428S.
28. Ewart CJ, Lankford AB, Gamboa MG. Successful closure
of abdominal wall hernia using the components separation
technique. Ann Plast Surg 2003;50:269273.
29. Geerts WH, Pineo GF, Heit JA, et al. Prevention of
venous thromboembolism: The Seventh ACCP Confer-
ence on Antithrombotic and Thrombolytic Therapy. Chest
2004;126:338S400S.
Section IX
HEMATOPOIETIC
Stephen R. T. Evans, MD
It is a mistake to suppose that men succeed through success; they much oftener
succeed through failures. Precept, study, advice, and example could never have
taught them so well as failure has done.Samuel Smiles

56
Laparoscopic Splenectomy
Diana M. Weber, MD and Aarti Mathur, MD

INTRODUCTION performance of more than 10 cases has been recom-

The birth of the laparoscopic era has revolutionized the
surgical approach to the abdomen. Since Delaitres per-
formance of the rst laparoscopic splenectomy (LS) in
1991, LS has come to replace open splenectomy (OS),
and it is now the standard procedure for patients with
hematologic disorders.1 LS is associated with a lower
complication rate than that of OS, primarily owing to the
greater visualization of anatomic structures and the less
invasive nature of laparoscopy.2 However, because of the
fragile parenchyma, rich blood supply, and intimate rela-
tion to intra-abdominal organs such as the stomach, colon,
and pancreas, LS, even when performed by experienced
surgeons, is not without complications.35
Multivariate analyses show that these parameters increase
the risk of complications associated with LS: learning
curve of the surgeon, patient age, degree of hematologic
malignancy, and extent of splenomegaly dened as splenic
weight greater than 1000 g or craniocaudal length greater
than 20 cm.68 Splenomegaly may compromise the sur-
geons ability to manipulate the spleen, achieve hemosta-
sis, and retrieve the specimen.9 Malignant spleens also
tend to weigh more than benign spleens.10,11 Large splenic
size of greater than 2 kg has been shown to have a com-
plication rate of 63% versus 25% for a normal-sized
spleen.11 Complications are also greater in elderly patients
(53% vs. 13%).7,12 Because LS has a steep learning curve,
mended to achieve competency.1216
INDICATIONS 17
Red blood cell disorders: sphereocytosis, elliptocytosis,
autoimmune hemolytic anemia, thalassemias, sickle cell
White blood cell disorders: lymphoma (staging), myelo-
brosis, chronic lymphocytic leukemia, chronic myelog-
enous leukemia, hairy cell leukemia
Platelet disorders: idiopathic thrombocytopenic
purpura, thrombotic thrombocytopenic purpura,
Evans syndrome
Secondary hypersplenism: cirrhosis, cystic brosis
Miscellaneous: splenic trauma, abscess, cyst, tumor,
angiomatosis, splenic artery aneurysms, Gauchers
disease, sarcoidosis
CONTRAINDICATIONS 18
Severe coagulopathy or thrombocytopenia (platelet
<20 K)
Severe splenomegaly dened as a craniocaudal access
greater than 30 cm.
Pregnancy
Calcied splenic artery
 572 SECTION IX: HEMATOPOIETIC
Relative contraindication exists in patients with portal
hypertension secondary to the potential of life-
threatening hemorrhage and difculty achieving
hemostasis19
INSTRUMENTATION
Preparation for the procedure with the appropriate equip-
ment aids in performing a smooth operation and mini-
mizes complications. The essential equipment for LS is as
follows:
Angled laparoscope (30) 5 to 10 mm
5-mm graspers and dissector
Curved laparoscopic scissors
Linear laparoscopic stapling devicetwo should be
readily available
Ultrasonic dissector (harmonic)
Nylon extraction sac (500750 ml capacity)
Clip appliers
Suction cannula
PREOPERATIVE PREPARATION
All patients should be immunized against encapsulated
bacteria, and coagulopathies should be corrected.
Polyvalent pneumococcal, Haemophilus inuenzae, and
Neisseria meningitidis vaccines should be administered 1
to 2 weeks prior to surgery to allow time for an adequate
antibody response.1,10,20 Patients who have received corti-
costeroids within the previous year should be treated with
a stress dose to prevent acute adrenocortical insufciency.20
Splenic artery embolization is generally not indicated
unless the spleen is larger than 30 cm.21
OPERATIVE STEPS
Step 1 Position patient
Step 2 Trocar placement
Step 3 Abdominal exploration and search for accessory
spleens
Step 4 Mobilization of inferior pole of spleen
Step 5 Incision of lateral attachments to spleen
Figure 561 Ideal patient positioning for laparoscopic
splenectomy.
Step 6 Division of lower pole vessels
Step 7 Entrance to lesser sac and division of short
gastrics
Step 8 Dissection and ligation of splenic artery and
vein
Step 9 Place spleen into sac
Step 10 Division of remaining splenophrenic ligament
and closure of sac
Step 11 Morcellate and extract spleen
Step 12 Irrigation and hemostasis
Step 13 Trocar removal
OPERATIVE PROCEDURE
Positioning (Fig. 561)
In the earliest reports of LS, the procedure was per-
formed almost exclusively with the patient in the supine
position. The gradual evolution of this procedure has led
surgeons to perform the majority of LS using the hanging
spleen technique, with the patient in the right lateral
decubitus position with a kidney rest and about 30 of
reverse Trendelenburg.20 The peritoneal attachments of
the spleen are used to suspend it in place. Gravity facili-
tates retraction of the stomach, omentum, and colon and
allows slightly easier access and better visualization of the
posterior aspect of the hilum, reducing the frequency of
complications.20
Trocar Insertion1,20 (Fig. 562)
Life-threatening and less serious complications can occur
with trocar insertion. Complications, repair, and preven-
tion are discussed in Section I, Chapter 7, Laparoscopic
Surgery.
A standard three- or four-trocar technique is used,
placing the working ports along the left subcostal border.
The camera port site accommodating a 30 scope is placed
at the rim of the umbilicus in pediatric and slender patients;
for larger patients, this may need to be moved to the left
upper quadrant. A 5- to 12-mm port placed either crani-
ally or caudally in the medioclavicular line is used as a
working port as well as for the endovascular stapler. A
paramedial epigastric 5- to 12-mm port is used as a second
working port for the grasper and suction. An optional
fourth 5-mm trochar may be placed in the left anterior
 56 LAPAROSCOPIC SPLENECTOMY 573

Pancreas
Spleen
Colon
Kidney
Stomach

Figure 562 Trocar positioning for laparoscopic

splenectomy.

subcostal or subxiphoid space for retraction. If a hand- Prevention

assisted technique is to be used, the hand is introduced
through either a Pfannenstiel incision or a lower right or
left 5- to 6-cm abdominal incision.16,2125 Consequences,
repair, and prevention are discussed in Section I, Chapter
7, Laparoscopic Surgery.
Abdominal Exploration and Search for
an Accessory Spleen (Fig. 563)
Accessory spleens are present in about 25% of patients
and can cause recurrence of the hematologic disease after
splenectomy.10,19,26,27
Laparoscopic magnication may improve detection of
accessory splenic tissue.6 Careful and systematic dissec-
tion of splenic hilum, lateral lesser sac, pancreatic tail,
splenocolic, and gastrosplenic ligaments allows accurate
identication.17 This area is explored by gently retract-
ing the spleen laterally and opening the gastrosplenic
ligaments with endoshears. Once detected, an acces-
sory spleen should be resected because it may later be
mistaken for hematoma as the operation progresses,
and it can cause disease recurrence or treatment failure.19
Accessory spleens can be found in a variety of locations
with the following frequencies18:

Hilar region 54%

Recurrent Thrombocytopenia
Pedicle 25%
Consequence Greater omentum 12%
Recurrent thrombocytopenia may occur, especially Tail of pancreas 6%
in patients with idiopathic thrombocytopenic purpura, Splenocolic ligament 2%
secondary to failure to remove accessory spleens.25,28,29 Mesentery 0.5%
Although most recurrences happen within the rst 2 Left ovary 0.5%
years after splenectomy, they have been reported up to
18 years later.10 Mobilize Inferior Pole of
Grade 2/3 complication the Spleen/Splenic Flexure
Colonic Injury
Repair
If disease recurrence is identied, a denatured red blood Consequence
cell scintigraphy or sulfur colloid scan may be per- INJURY may result in spillage of colonic contents into
formed to identify the accessory spleen. Reoperation the abdominal cavity and resultant peritonitis.
may be necessary for symptomatic disease.25,26 Grade 1/3 complication
 574 SECTION IX: HEMATOPOIETIC
Stomach
Pancreas
3
4 Colon
Repair
Early identication of the perforation and laparoscopic
repair with primary closure are essential.28
Prevention
Dissection of the splenic exure can be accomplished
by a combination of sharp dissection and the ultrasonic
dissector. Knowledge of the anatomy, gently rotating
the colon medially and inferiorly out of the eld, and
the placement of the patient in the appropriate position
will minimize this injury.30
Capsular Bleeding
Consequence
Hemorrhage originating in the parenchyma is usually
less dangerous than vascular bleeding, but it impairs
visualization for further dissection.19
Grade 1 complication
Repair
Hemorrhage originating from the parenchyma can be
managed by clamping the artery and vein, by applying
slight pressure with gauze, or using either collagen
eece or brin adhesive.1,19 If signicant bleeding
occurs, conversion to an open procedure may be
required.
Prevention
Capsular bleeding, which is seen more frequently in
patients with splenomegaly, may occur at any time
Spleen
Accessory Spleen Locations
1. Hilar region
2. Greater omentum
3. Tail of pancreas
4. Splenocolic ligament Figure 563 Locations of acces-
5. Pedicle sory spleens.
during LS, mostly from excessive manipulation or
grasping of the spleen.31 Appropriate gentle traction of
structures away from the spleen and clear visualization
of the spleen minimize capsular injury.
Incise Lateral Attachments to the Spleen
(Splenorenal and Splenophrenic) (Fig. 564)
Diaphragmatic Injury
Consequence
A small puncture/cautery injury in the diaphragm,
especially of the muscled part, may be amplied
by the presence of pneumoperitoneum, causing a
pneumothorax.19,26
Grade 2/3 complication
Repair
Increased peak airway pressures along with paradoxical
diaphragmatic motion indicate diaphragmatic injury.
Once identied, immediate intraoperative needle
decompression followed by tube thoracostomy after
completion of the procedure reexpands the lung.26
It is not always necessary to repair the diaphragmatic
perforation.
Prevention
Knowledge of anatomy and meticulous dissection help
to avoid this complication. In addition, appropriately
positioning the patient in reverse Trendelenburg allows
for greater visualization of this space and increases the
distance to the diaphragm. The right lateral decubitus

Spleen
Figure 564 Incising the lateral
attachments to the spleen.
position, which takes advantage of gravity to expose
retroperitoneal attachments even in the presence of
dense diaphragmatic adhesions, reduces the frequency
of potential diaphragmatic injury.31
Enter the Lesser Sac and Divide
Divide the Lower Pole Vessels
the Short Gastrics (Fig. 565)
Bleeding
Bleeding
Inferior polar arteries, usually originating from the left
gastroepiploic arteries, occur in approximately 80% of
patients, numbering from one to ve vessels. These vessels
are relatively simple to dissect and are typically ligated with
the ultrasonic dissector.
Consequence
Bleeding from the inferior polar vessels may be a
life-threatening hemorrhage or may just become a
hindrance to the operation because rapidly accumulat-
ing blood can impair visualization.19
Grade 1/3 complication
Repair
Bleeding that impairs visualization can be stopped with
clips, electrocoagulation, or the ultrasonic dissector.3
Bleeding resulting in life-threatening hemorrhage
requires conversion to laparotomy and further control.
Prevention
Appropriate traction allows for visualization of tissues
prior to dissection. It is crucial to identify larger vessels
that may need to be clipped prior to division with the
ultrasonic dissector. The ultrasonic dissector should
completely envelop all visible vessels within its grasp
56 LAPAROSCOPIC SPLENECTOMY 575
Diaphragm
to avoid incomplete division of a vessel, resulting
in bleeding. Excessive traction during ligation may
tear the tissue and prevent achievement of complete
hemostasis.
Consequence
Although not life threatening, bleeding from the
short gastrics can become a hindrance to the opera-
tion because rapidly accumulating blood can impair
visualization.19
Grade 1 complication
Repair
Bleeding can be stopped with clips, electrocoagulation,
ultrasonic dissector, or bipolar cautery.3 Sponges and
Gelfoam may aid in control of the bleeding. If bleeding
persists or is uncontrollable, conversion to an open
procedure may be required.
Prevention
The appropriate use of the harmonic shears has greatly
reduced the incidence of bleeding from the short gas-
trics. The entire circumference of the vessel should be
placed within the harmonic scalpel to avoid incomplete
ligation, resulting in bleeding. During ligation, excess
traction may result in tearing of tissue and incomplete
hemostasis. Undue retraction on the stomach to tent
and isolate these vessels may also result in shearing and
premature release of tissues, causing bleeding.
 576 SECTION IX: HEMATOPOIETIC
Spleen
Stomach
Transverse colon
Gastric Perforation (Gastrotomy)/Necrosis
Consequence
Gastrotomy results in the spillage of gastric contents
into the abdominal cavity, resulting in peritonitis. This
can present immediately in the operating room from
direct penetrating injury to the stomach during dissec-
tion, or it may present later with a delayed perforation
from thermal injury or serosal tears during dissection.
Use of a harmonic scalpel near the stomach can con-
tribute to thermal or serosal injuries that may result in
delayed perforation.
Grade 1/3/5 complication
Repair
If recognized during the procedure, primary repair of
a gastric perforation may be attempted laparoscopically;
however, it is recommended to convert to laparo-
tomy.24 A delayed perforation requires laparotomy for
repair.
Prevention
It is not uncommon for the proximal greater curve of
the stomach to directly abut the spleen. Therefore,
appropriate traction and clear visualization of tissues
during division of the short gastrics are essential. Care
must also be taken to appreciate the structures that the
heated portion of the dissector may touch. The ultra-
sonic dissector allows for less dissection around the
Figure 565 Entering the lesser sac and dividing the
short gastric vessels.
vessels close to the stomach and spleen, reducing the
incidence of gastric perforation.
Dissect and Ligate the Splenic Artery and Vein
(Figs. 566 and 567)
Hilar Bleeding/Hemorrhage
This remains the surgeons key concern, because the need
for transfusions in some series has exceeded 25%.7,9
Consequence
Hemorrhage and associated shock may result from
massive blood loss.
Grade 3/5 complication
Repair
Bleeding from the main artery and vein mandates
conversion to open laparotomy via a left subcostal
incision and hemorrhage control. Intraoperative staple
line bleeding can be managed with individual clips or
sutures placed along that portion of the staple line.
Postoperative bleeding from the staple line may be
managed by splenic artery embolization.19
Prevention
Clear understanding of splenic anatomy is crucial.
Gentle retraction of the inferior pole exposes the hilar
groove and allows evaluation of the vascular anatomy.
The splenic vasculature has two common variations, the
 56 LAPAROSCOPIC SPLENECTOMY 577

Spleen

Stomach
Kidney

Pancreas

Hilus

Figure 566 Dissection and ligation of

the splenic artery and veinanterior view.

Spleen

Splenic a., v.

Pancreas

Figure 567 Dissection and liga-

tion of the splenic artery and vein
posterior view.
 578 SECTION IX: HEMATOPOIETIC
magistral and the distributive pattern.32 In the distribu-
tive pattern, multiple branches arise from the main
trunks approximately 2 to 3 cm from the hilum, and
each terminal branch should be divided between clips.
In the magistral pattern, the pedicle formed by the
artery and vein enters the hilum as a compact bundle
and should be transected en bloc with a single applica-
tion of a vascular linear stapler. A window can be
created above the hilar pedicle in the splenorenal liga-
ment so that all structures are included within the
markings of the linear stapler under direct vision.
Looking at the internal surface of the spleen will aid in
differentiating between these two vascular patterns. If
the splenic vessels entering the spleen cover only 25%
of the internal surface, a magistral pattern is present.
Conversely, if the splenic vessels cover greater than 75%
of the internal surface, a distributive pattern is present.32
The number of splenic branches is also related to the
presence of the number of notches on the spleen. The
number of notches have been found to correlate with
the distributive anatomy and may be used as a helpful
indicator at the beginning of the dissection.16,32
Proper positioning of the stapling device around the
entire splenic hilum, facilitated by hilar dissection and
splenic elevation, decreases the risk of perioperative bleed-
ing and minimizes potential instrument failures.5,31 Prom-
inent splenic vessels, perihilar fat, and the relatively narrow
jaw opening of currently available staplers may lead to
increased difculty in encompassing the entire hilum.
Therefore, clean and delicate dissection of the artery and
vein helps exclude extraneous tissue and prevent wedging
of the stapler into place, which would promote rupture of
smaller pancreatic and splenic blood vessels.5,33,34 The ends
of the stapling device on both sides should be visualized
prior to ring. Placement of metallic endoclips near the
hilum may interfere with the gastrointestinal anastomosis
(GIA) stapler. Inclusion of a clip in the GIA stapler may
result in massive bleeding because the stapler will cut but
not ligate. Prior to stapling, another stapler should be
readily available in the case of equipment failure or partial
transaction of the hilum.
In the case of splenomegaly, the perisplenic ligaments
are relatively shorter and the splenic hilum is deeply
hidden, increasing the risk of bleeding.31 Hand-assisted
laparoscopic surgery has shown to decrease rates of bleed-
ing by providing increased exposure.2123
Preoperative splenic artery embolization has not been
proved to decrease morbidity, but it may be considered
for postoperative splenic artery staple line bleeding.19
Pancreatic Injury
This is the most common morbidity associated with
LS.35
Consequence
Injury to the pancreas may result in a wide array of
manifestations from asymptomatic hyperamylasemia
to pancreatitis, peripancreatic uid collection,
abscess, pancreatic stula, and pancreatic tail
necrosis.4,19,3537
Grade 1/2 complication
Repair
If an intraoperative injury is suspected, a closed suction
drain should be placed and exited through a trocar site.
Amylase levels should be checked on the drains post-
operatively, and if elevated, the diet should be advanced
more slowly. The drain may be removed when the
output is less than 50 ml/24 hr. A uid collection may
be managed by percutaneous drainage.35
Prevention
Knowledge of anatomy can guide the surgeon to iden-
tify landmarks and apply the stapler in close proximity
to the hilum on a site beyond the tip of the pancreas.30
In 75% of patients, the tail of the pancreas is less than
1 cm from the splenic hilum, and in 30% of patients,
the tail is in direct contact with the hilum.25 Therefore,
great care must be taken during hilar dissection.
Ironically, the incidence of pancreatic injury may be
increased as a result of the same factors that have facil-
itated the success of this procedure. The lateral posi-
tioning of the patient alters the orientation between
the spleen and the pancreatic tail by allowing the hilum
to lengthen.19 Limited exposure to the splenic hilum,
especially in patients with splenomegaly, increases
the risk of pancreatic injury. Therefore, meticulous
skeletonization of the artery and vein as well as applica-
tion of the stapler in close proximity to the hilum
minimizes the risk of transection or injury to the
pancreatic tail.35 Multiple applications of the GIA
stapler to prevent hilar bleeding may increase the risk
of pancreatic injury.36
In patients with splenomegaly, the hilar structures can
pose a serious challenge because they are deeply hidden.
Early use of hand-assisted devices in the course of LS for
large spleens may help to minimize this occurrence.38
Some institutions routinely place Jackson-Pratt drains
in the splenic fossa after hand assisted laparoscopic
splenectomy (HALS) and check amylase on postoperative
day 1.39
Place the Spleen into the Sac, Morcellate,
and Extract (Fig. 568)
Splenosis
Consequence
Residual splenic tissue present in abnormal locations
usually remains asymptomatic and can be an incidental
nding on imaging many years later, mimicking a
tumor. In symptomatic patients, it may cause pain or
disease recurrence.29
Grade 1/2/3 complication

Figure 568 Placing the spleen into a bag.
Repair
Laparoscopic excision is indicated for symptomatic
disease, occasionally with the aid of an argon beam
coagulator.40
Prevention
Gentle and minimal manipulation of the spleen to
avoid capsular tears resulting in splenic spillage aids
in preventing this complication.41 The quality of dissec-
tion, absence of hemorrhage, copious irrigation, and
use of a large specimen bag to extract the spleen all
minimize the risk of splenosis.20,24,25 Morcellation
should be performed inside the specimen bag with
either ngers or atraumatic forceps.32
Irrigate and Achieve Hemostasis
Intra-abdominal/Subphrenic Abscess
Consequence
Development of an abscess typically occurs within
the rst 30 days and is associated with abdominal pain,
nausea, vomiting, fever, and rarely, death.4,17
Grade 2/3/5 complication
Repair
Intra-abdominal and subphrenic abscesses require a
drainage procedure, most commonly, a percutaneous
drain performed by interventional radiology.10,16,28 A
small percentage may not easily be accessed via radio-
graphic guidance and may require reoperation.
Prevention
Copious irrigation and suction until the irrigant uid
is clear and assurance that hemostasis has been achieved
56 LAPAROSCOPIC SPLENECTOMY 579
Spleen
minimize the risk of abscess formation. Preoperative
exposure to chemotherapy or steroids increases the risk
of infectious complications.
Retroperitoneal Hematoma
Consequence
Retroperitoneal hematoma is usually discovered in the
rst several postoperative days with a dropping hema-
tocrit, pain, and symptomatic anemia.26,41
Grade 2/3 complication
Repair
If the hematocrit does not stabilize, intervention is
required in the form of reexploration or laparoscopic
drainage.10,26
Prevention
Adequate hemostasis and copious irrigation reduce the
risk of a hematoma.
Trocar Removal
Wound Site Complications
Wound site complications include port site hernias, wound
infections, and abdominal wall hematomas.7,28 All of these
complications can occur with any form of laparoscopic
surgery and are discussed in Section I, Chapter 7, Lapa-
roscopic Surgery. In general, ports should be removed
under direct vision and fascia of all ports of 10 mm or
larger should be closed to avoid port site herniation.37
Morbidity at the surgical site is minimized by hemostasis
prior to closure.26
 580 SECTION IX: HEMATOPOIETIC
Other Complications
Portal/Splenic Vein Thrombosis
Thrombosis of the portal venous system has been reported
as a possible cause of death after splenectomy. The reported
incidence of portal/splenic vein thrombosis (PSVT) after
LS from routine postoperative surveillance ultrasound is
as high as 55% in some series.42,43 Although most patients
are asymptomatic, some may present with fever of
unknown origin, intestinal infarction, variceal hemor-
rhage, and hepatic failure in the short term.43,44 Preexist-
ing coagulation abnormalities and a large splenic mass may
be risk factors for postsplenectomy PSVT.43 Transient
thrombocytosis develops after splenectomy in 60% to 75%
of patients.45 In addition to the coagulation abnormalities
that these patients may have, it has been postulated that
the surgical technique itself may inuence the incidence
of this complication. Pneumoperitoneum causes a hyper-
coagulable state during laparoscopic surgery.46 In patients
with splenomegaly, the large stump of splenic vessels
causes turbulence that may enhance coagulation.4446
Routine surveillance imaging is not warranted; however,
high-risk patients may have postoperative surveillance.
Treatment for symptomatic patients ranges from antico-
agulation and/or systemic thrombolytics to local, via the
superior mesenteric artery, or percutaneous transhepatic
thrombolysis. Variceal hemorrhage requires endoscopic
control.46
Grade 1/2 complication
Overwhelming Postsplenectomy Infection
Removal of the spleen, which functions as a lter for
encapsulated bacteria, puts the patient at risk for develop-
ing a life-threatening fulminant infection with a mortality
rate greater than 50%.4750 Risk factors include younger
patient age and hematologic malignancy. The syndrome
typically occurs within the rst 6 months postoperatively.
It begins with nonspecic symptoms that rapidly progress
in 24 to 48 hours to progressive hypotension, dissemi-
nated intravascular coagulation, purpuric lesions in the
extremities, acute respiratory insufciency, metabolic
acidosis, and coma.47,48 Immediate high-dose pencillin is
the initial treatment, and vancomycin and ceftriaxone are
reserved for patients in areas where penicillin resistant
Streptococcus pneumoniae is present. Preventive strategies
fall into three major categories including chemoprophy-
laxis, immunoprophylaxis, and patient education. Pneu-
mococcal, meningococcal, and H. inuenzae type B
vaccines should be administered at least 14 days prior
to or soon after splenectomy. Booster injections of the
pneumococcal vaccine should be considered every 5 to
6 years. Annual inuenza immunization is advisable.
Penicillin prophylaxis is indicated in the rst 5 years of
life or the rst 2 years postoperatively in high-risk adults,
such as those with hematologic malignancies, severe liver
disease, or immunocompromised states. A lack of consen-
sus exists among experts regarding lifelong prophylaxis;
however, it may be considered in immunocompromised
patients.50
Grade 1/5 complication
REFERENCES
1. Uranues S, Alimoglu O. Laparoscopic surgery of the
spleen. Surg Clin North Am 2005;85:7590.
2. Winslow ER, Brunt ML. Perioperative outcomes of
laparoscopic versus open splenectomy: a meta-analysis with
an emphasis on complications. Surgery 2003;134:647
655.
3. Brodsky JA, Brody FJ, Walsh RM, et al. Laparoscopic
splenectomy. Surg Endosc 2002;16:851854.
4. Glasgow RE, Mulvihill SJ. Laparoscopic splenectomy.
World J Surg 1999;23:384388.
5. Kercher KW, Novitsky YW, Czerniach DR, Litwin DEM.
Staple line bleeding following laparoscopic splenectomy:
intraoperative prevention and postoperative management.
Surg Laparosc Endosc Percutan Tech 2003;13:353
356.
6. Rosen M, Brody F, Walsh M, et al. Outcome of laparo-
scopic splenectomy based on hematologic indication. Surg
Endosc 2002;16:272279.
7. Tagarona EM, Espert JJ, Bombuy E, et al. Complications
of laparoscopic splenectomy. Arch Surg 2000;135:1137
1140.
8. Duperier T, Brody F, Felsher J, et al. Predictive factors
for successful laparoscopic splenectomy in patients with
immune thrombocytopenic purpura. Arch Surg 2004;139:
6166.
9. Patel AG, Parker JE, Wallwork B, et al. Massive spleno-
megaly is associated with signicant morbidity after lap
splenectomy. Ann Surg 2003;238:235240.
10. Rosen M, Brody F, Walsh RM, et al. Outcome of
laparoscopic splenectomy based on hematological indica-
tion. Surg Endosc 2002;16:272279.
11. Horowitz J, Smith JL, Weber TK, et al. Postoperative
complications after splenectomy for hematologic malig-
nancies. Ann Surg 1996;233:290296.
12. Kavic SM, Segan RD, Park AE. Laparoscopic splenectomy
in the elderly: a morbid procedure? Surg Endosc 2005;
19:15611564.
13. Peters MB, Camacho D, Ojeda H, et al. Dening the
learning curve for laparoscopic splenectomy for immune
thrombocytopenic purpura. Am J Surg 2004;188:522
525.
14. Pace DE, Chiasson M, Schlachta M, et al. Laparoscopic
splenectomy: does the training of minimally invasive
surgical fellows affect outcomes? Surg Endosc
2002;16:954956.
15. Rege RV, Joehl RJ. A learning curve for laparoscopic
splenectomy at an academic institution. J Surg Res
1999;81:2732.
16. Kathkhouda N, Manhas S, Umbach TW, et al. Laparo-
scopic splenectomy. J Laparosc Adv Surg Tech 2001;11:
383390.
17. Glasgow RE, Yee LF, Mulvihill SJ. Laparoscopic splenec-
tomy: the emerging standard. Surg Endosc 1997;11:108
112.

18. Park A. Laparoscopic splenectomy. In Cameron J (ed):
Current Surgical Therapy, 8th ed. Philadelphia: Elsevier
Mosby, 2004; pp 12541257.
19. Park A, Taragona EM, Trias M. Laparoscopic surgery of
the spleen: state of the art. Arch Surg 2001;386:230
239.
20. Schlinkert RT, Teotia SS. Laparoscopic splenectomy. Arch
Surg 1999;134:99103.
21. Taragona EM, Balague C, Cerdan G, et al. Hand-assisted
laparoscopic splenectomy in cases of splenomegaly. Surg
Endosc 2002;16:426430.
22. Taragona EM, Gracia E, Rodriguez M, et al. Hand-
assisted laparoscopic surgery. Arch Surg 2003;138:133
141.
23. Rosen M, Brody F, Walsh M, Ponsky J. Hand-assisted
laparoscopic splenectomy vs conventional laparoscopic
splenectomy in cases of splenomegaly. Arch Surg 2002;
137:13481352.
24. Poulin EC, Mamazza J. Laparoscopic splenectomy: lessons
from the learning curve. Can J Surg 1998;41:2836.
25. Delaitre B, Blezel E, Samana G, et al. Laparoscopic
splenectomy for idiopathic thrombocytopenic purpura.
Surg Laparosc Endosc Percut Tech 2002;12:413419.
26. Brodsky JA, Brody FJ, Walsh RM, et al. Laparoscopic
splenectomy: experience with 100 cases. Surg Endosc
2002;16:851854.
27. Gigot JF, Jamar F, Ferrant A, et al. Inadequate detection
of accessory spleens and splenosis with laparoscopic
splenectomy. Surg Endosc 1998;12:101106.
28. Pomp A, Gagner M, Salky B, et al. Laparoscopic splenec-
tomy: a selected retrospective review. Surg Laparosc
Endosc Percutan Tech 2005;15:139143.
29. Schwartz J, Eldor A, Szold A. Laparoscopic splenectomy
in patients with refractory or relapsing thrombotic
thrombocytopenic purpura. Arch Surg 2001;136:1236
1238.
30. Laparoscopic splenectomy. In Scott-Conner CEH,
Dawson DL (eds): Operative Anatomy, 2nd ed. Philadel-
phia: Lippincott Williams & Wilkins, 2003; pp 362366.
31. Tan M, Zheng C, Whu Z, et al. Laparoscopic splenec-
tomy: the latest technical evaluation. World J Gastroen-
terol 2003;9:10861089.
32. Poulin EC, Schlachta CM, Mamazza J. Laparoscopic
splenectomy. In Souba WW (ed): American College of
Surgeons ACS Surgery: Principles and Practice. New York:
Web MD Inc, 2004; pp 520534.
33. Miles WFA, Greig JD, Wilson RG, Nixon SJ. Technique
of laparoscopic splenectomy with a powered vascular linear
stapler. Br J Surg 1996;83:12121214.
34. Machado MAC, Makdissi FF, Herman P, et al. Exposure
of splenic hilum increases safety of laparoscopic splenec-
56 LAPAROSCOPIC SPLENECTOMY 581
tomy. Surg Laparosc Endosc Percutan Tech 2004;14:
2325.
35. Chand B, Walsh RM, Ponsky J, Brody F. Pancreatic
complications following laparoscopic splenectomy. Surg
Endosc 2001;15:12731276.
36. Klinger PJ, Tsiotos GG, Glaser KS, Hinder RA. Laparo-
scopic splenectomy: evolution and current status. Surg
Laparosc Endosc Percutan Tech 1999;9:18.
37. Chan SW, Hensman C, Waxman BP, et al. Technical
developments and a team approach leads to an improved
outcome: lessons learnt implementing laparoscopic
splenectomy. Aust N Z J Surg 2002;72:523527.
38. Terrosu G, Baccarani U, Bresadola M, et al. The impact
of splenic weight on laparoscopic splenectomy for
splenomegaly. Surg Endosc 2002;16:103107.
39. Smith L, Luna G, Merg A, et al. Laparoscopic splenec-
tomy for treatment of splenomegaly. Am J Surg 2004;
187:618620.
40. Serur E, Sadana N, Rockwell A. Laparoscopic manage-
ment of abdominal pelvic splenosis. Obstet Gynecol
2005;106:11701171.
41. Corcione F, Esposito C, Cuccurullo D, et al. Technical
standardization of laparoscopic splenectomy: experience
with 105 cases. Surg Endosc 2002;16:972974.
42. Winslow ER, Brunt LM, Drebin JA, et al. Portal vein
thrombosis after splenectomy. Am J Surg 2002;184:631
636.
43. Ikeda M, Sekimoto M, Takiguchi S, et al. High incidence
of thrombosis of the portal venous system after laparo-
scopic splenectomy. Ann Surg 2005;241:208216.
44. Brink JS, Brown AK, Palmer BA, et al. Portal vein
thrombosis after laparoscopy-assisted splenectomy and
cholecystectomy. J Pediatr Surg 2003;38:644647.
45. Fransciosi C, Romano F, Caprotti R, et al. Splenoportal
thrombosis as a complication after laparoscopic splenec-
tomy. J Laparoendosc Adv Surg Tech 2002;12:273276.
46. Kercher KW, Sing RF, Watson KW, et al. Transhepatic
thrombolysis in acute portal vein thrombosis after
laparoscopic splenectomy. Surg Laparosc Endosc 2002;12:
131136.
47. Opal SM. Splenectomy and splenic dysfunction. In Cohen
J, Powderly WG (eds): Infectious Diseases, 2nd ed.
Philadelphia: Mosby, 2004; pp 11451149.
48. Bridgen ML, Pattullo AL. Prevention and management of
overwhelming postsplenectomy infection: an update. Crit
Care Med 1999;27:836842.
49. El-Alfy MS. Overwhelming postsplenectomy infection: is
quality of patient knowledge enough for prevention?
Hematol J 2004;5:7780.
50. Newland A, Provan D, Myint S. Preventing severe
infection after splenectomy. BMJ 2005;331:417418.
57
Supraclavicular Lymph Node Biopsy
Diana M. Weber, MD and Eleanor Faherty, MD
INTRODUCTION
The supraclavicular lymph node biopsy was rst described
in the literature in 1949 by Daniels.1 It has remained a
diagnostic tool for intrathoracic and/or metastatic disease,
even with the development of more noninvasive proce-
dures such as ultrasound-guided biopsy and scalene biopsy
during mediastinoscopy.24 The supraclavicular lymph
nodes are also called the scalene nodes because of their
close proximity with the scalene muscles.
The supraclavicular fossa or scalene triangle is bounded
medially by the sternal head of the stenocleidomastoid,
laterally by the clavicular head of the same muscle, and
inferiorly by the clavicle. The lymph nodes are invested in
a fat pad that lies directly over the anterior scalene muscle,
just lateral to the carotid sheath. The phrenic nerve and
the transverse cervical and suprascapular arteries run
through this region, as does the thoracic duct on the left.5
In experienced hands, the procedure is very simple;
however, a lack of understanding of the anatomy may
result in complications including bleeding, thoracic duct
injury, and phrenic or recurrent laryngeal nerve injury.
Studies have reported an 8% morbidity rate and a 3%
mortality rate.6,7
The scalene lymph nodes are a common location for
metastasis of several cancers, the most common of which
is lung cancer.8 In the United States, lung cancer has the
highest mortality of all cancers, and disease spread to the
scalene lymph nodes (N3) may contraindicate surgical
therapy.4 Esophageal cancer studies have also demon-
strated that 15% of patients have positive scalene nodes at
presentation.9 Sarcoidosis, a benign but debilitating con-
dition, has also been shown to present with supraclavicu-
lar lymphadenopathy.10
INDICATIONS
Lung cancer
Esophageal cancer
Cervical cancer
Testicular cancer
Sarcoidosis
OPERATIVE STEPS
Step 1 Skin incision
Step 2 Incise platysma
Step 3 Retract heads of sternocleidomastoid muscles
Step 4 Dissection of scalene fat pad
Step 5 Closure
OPERATIVE PROCEDURE
Dissection of the Scalene Fat Pad
Vessel Injury
The carotid sheath, containing the carotid artery and
internal jugular vein, lies medial to the scalene fat pad and
may be injured during dissection. Branches of the thyro-
cervical trunk, the transverse cervical and suprascapular
arteries, also run through the fat pad and may be injured
and result in bleeding.
Consequence
Bleeding may occur if vessels are injured or transected.
If the carotid artery is involved, bleeding may be
massive. There may also be neurologic compromise if
there is contralateral carotid disease.
Grade 1 or 3 complication
Repair
Ligation may be performed of the transverse cervical
and suprascapular arteries if injured. Primary repair
should be completed for any injury or transection of
the carotid artery or internal jugular vein.
Prevention
The carotid sheath runs in the medial supraclavicular
fossa, close to the sternal head of the sternocleidomas-
troid muscle. Gentle medial retraction of the sheath
during dissection should protect these structures.
Phrenic Nerve Injury
Consequence
The phrenic nerve innervates the diaphragm and is
important in respiration. Patients with severe respira-
tory disease may have worsening symptoms if the
 584 SECTION IX: HEMATOPOIETIC
phrenic nerve is compromised. Unilateral phrenic nerve
injury is generally tolerated in most patients.
Grade 4 complication
Prevention
The phrenic nerve runs along the anterior scalene
muscle in the same direction as its bers. It runs deep
in the scalene fat pad. Careful identication of the nerve
should occur during sharp dissection to prevent
injury.
Chylous Fistula
Consequence
A chyle leak from a thoracic duct injury may result in
a failure to thrive in patients owing to weight loss and
debility from the loss of triglycerides.
Grade 2/3 complication
Repair
Conservative management is possible in some patients.
Parenteral nutrition or feeding with only medium-chain
fatty acids may help to decrease chyle production and
allow spontaneous closure. In patients with chronic
cough or those in whom conservative treatment has
failed, primary surgical repair or ligation of the thoracic
duct should occur.11
Prevention
If lymph nodes are nonpalpable, or whenever possible,
the scalene lymph node biopsy should be done on the
right to avoid possible thoracic duct injury. The duct
can be visualized in the medial side of the supracla-
vicular fossa where it joins the subclavian vein. Careful
identication of the duct should occur during dissec-
tion to prevent injury. In patients who are awake for
biopsy, the surgeon may ask the patient to cough at
the completion of the procedure to check for a jet of
chyle (milky, white uid), which would indicate a
ductal injury.
REFERENCES
1. Daniels AC. A method of biopsy useful in diagnosing
certain intrathoracic diseases. Dis Chest 1949;16:360.
2. Fultz PJ, Harrow AR, Elvey SP, et al. Sonographically
guided biopsy of supraclavicular lymph nodes: a simple
alternative to lung biopsy and more invasive procedures.
AJR Am J Roentgenol 2003;180:14031409.
3. Fultz PJ, Feins RH, Strang JG, et al. Detection and
diagnosis of nonpalpable supraclavicular lymph nodes in
lung cancer at CT and US. Radiology 2002;222:245
251.
4. Lee JD, Ginsberg RJ. Lung cancer staging: the value of
ipsilateral scalene lymph node biopsy performed at
mediastinoscopy. Ann Thorac Surg 1996;62:338341.
5. Cervical lymph node biopsy and scalene node biopsy. In
Scott-Conner CEH, Dawson DL (eds): Operative
Anatomy, 2nd ed. Philadelphia: Lippincott Williams &
Wilkins, 2003; pp 6973.
6. Ketcham AS, Sindelar WF, Feliz EL, Bagley DH. Diag-
nostic scalene node biopsy in the preoperative evaluation
of the surgical cancer patient: a 5 year experience with
108 cases and literature review. Cancer 1976;38:948
952.
7. Skinner DB. Scalene lymph node biopsy: Reappraisal of
risks and indicators. N Engl J Med 1963;268:1324
1329.
8. Lynch DF, Richie JP. Supraclavicular node biopsy in
staging testis tumors. J Urol 1980;123:3940.
9. Van Overhagen H, Lameris JS, Berger MY, et al. Supra-
clavicular lymph node metastases in carcinoma of the
esophagus and gastroesophageal junction: assessment with
CT, US and US-guided ne-needle aspiration biopsy.
Radiology 1991;179:155158.
10. Lohela P, Tikkakoski T, Strengell L, et al. Ultrasound-
guided ne-needle aspiration cytology of non-palpable
supraclavicular lymph nodes in sarcoidosis. Acta Radiol
1996;37:896899.
11. Wertheimer M, Hughes RK. Scalene lymph node biopsy;
prevention of postoperative chylous stula. Am J Surg
1971;122:121122.
Section X
VASCULAR SURGERY
Richard F. Neville, MD
I have not failed. Ive just found 10,000 ways that wont work.Thomas A. Edison
58
Carotid Endarterectomy
Dahlia Plummer, MD and Richard F. Neville, MD
INTRODUCTION
In the United States, the incidence of new and recurrent
stroke is estimated at approximately 700,000 per year,
with over 80% attributable to an ischemic etiology.1
Surgery for the prevention of ischemic stroke from ath-
erosclerotic extracranial vascular disease was rst per-
formed by Eastcott, Pickering and Rob in 1954. A carotid
endarterectomy (CEA) was performed for symptomatic
atheroembolic disease. The procedure fell into disfavor by
many in the ensuing years until two prospective, random-
ized trials (North American Symptomatic Carotid Endar-
terectomy Trial [NASCET] and Asymptomatic Carotid
Atherosclerosis Study [ACAS]) as well as numerous corol-
lary trials demonstrated CEA to be effective for symptom-
atic and asymptomatic patients with appropriate degrees
of stenosis.25 CEA is a procedure heavily dependent on
the experience and technique of the operating surgeon.
The actual surgical technique that is the foundation of
CEA has changed little, but patient selection, intraopera-
tive care, and postprocedural follow-up have been greatly
rened.
The CEA has long maintained a prominent position in
stroke prevention, and its efcacy has been borne out in
a number of landmark trials. Nationally, between 180,000
and 200,000 CEAs are performed each year.4 NASCET
and the European Carotid Stenosis Trial (ECST) both
demonstrated decreased stroke risk in symptomatic
patients undergoing CEA. Symptomatic patients, in a
medically treated cohort, with 70% or greater arterial ste-
nosis were shown to have a cumulative 2-year risk of
ipsilateral stroke of 26% versus 9% in those treated surgi-
cally; the absolute risk reduction was 17%.2 In the ACAS,
a lower risk of stroke and death was seen in patients
managed with surgery over matched controls receiving
medical management. The 5-year risk of stroke was 5.1%
in patients treated with surgery versus 11% in those treated
medically, with an absolute risk reduction of 5.9%.3 These
ndings accounted for a 53% relative risk reduction in the
surgical cohort over the 5-year study period.3
Unlike therapy for coronary and most other peripheral
vascular occlusive disease, the critical clinical aspect of
extracranial cerebrovascular disease is not chronic ischemia
and lack of blood ow, but embolic events. Although we
continue to use the degree of stenosis as a primary factor
in the evaluation of appropriate candidates for therapy,
symptoms are the most predictive nding. Much remains
to be done to determine the nature of plaque stability and
to develop an understanding of the critical events that
transform a dormant lesion into an active lesion with
acute changes and embolic phenomena.
Open surgical exposure of the carotid bifurcation results
in a small physiologic insult to the patient. Subcutaneous
exposure of the carotid bifurcation can be done with the
patient under either local or general anesthesia. The pro-
cedure requires a maximum amount of control through
employing distal control of the internal carotid, reversal
of ow in the internal carotid prior to restoring antegrade
ow, visual inspection and dbridement of the plaque
site, and control of the proximal and distal endpoints of
 586 SECTION X: VASCULAR SURGERY

the endarterectomy. CEA is based on ve fundamental
principles:
1. Minimal physiologic insultpredictable location and
subcutaneous exposure.
2. Arterial controlreliably achieved without additional
manipulation.
3. Maintenance of cerebral perfusion.
4. Plaque removalcomplete removal of embolic lesion.
5. Lumen enlargementendarterectomized vessel great-
er than 100% of native vessel diameter, especially with
patch angioplasty providing prevention of restenosis.
head toward the opposite side. The arms should be tucked
to the sides and the table slightly exed at the waist.
Proper positioning affords maximal exposure of the carotid
triangle. The geometry of the neck may also be enhanced
by using a shoulder roll to optimize neck extension.
Caution is exercised to avoid hyperextension because this
may place excessive tension on the vessels of the neck. The
patient should be prepared widely and draped in a manner
that allows exposure of the anterior cervical triangle. The
operative table may be rotated to provide the optimum
visibility for the operator.

KEY DECISION POINTS

Improper Positioning
Anesthesia: local/regional versus general Consequence
Intraoperative shunting: selective versus routine Loss of orientation. There is no substitute for caution
Arterial closure: primary versus patch and attention to detail during surgery. Notwithstand-
ing, exposure of the earlobe and chin serves to orient
the operator in left versus right side procedures. The
INDICATIONS angle of the mandible, the anterior border of the ster-
nocleidomastoid muscle, and the sternal notch should
Symptomatic stenosis greater than 50% be clearly visible.
Asymptomatic stenosis greater than 60% to 80% Grade 1 complication
Symptomatic ulcerated plaque type B/C
Asymptomatic ulcerated plaque type C Consequence
Hyperextension of the neck. It has been shown that
excessive angulation of the neck may result in mechan-
OPERATIVE STEPS ical compression of the posterior cerebral circulation,
and prolonged hyperextension could predispose a
Step 1 Patient positioning patient to stroke and should be avoided. The patho-
Step 2 Skin incision physiology of stroke, in this instance, is based on the
Step 3 Dissection and exposure of extracranial carotid combined effects of endothelial injury in the presence
artery of atherosclerosis. These features lead to up-regulation
Step 4 Arterial controlproximal and distal of the inammatory cascade, vasoconstriction, and sub-
Step 5 Evaluation of intracranial circulation sequent thrombosis and/or arterial occlusion. Arterial
a. Routine shunting dissection secondary to hyperextension has also been
b. Selective shunting described. Individuals identied with the biologic
c. Operation in awake patient markers of hypoplasia, carotid and vertebral occlusion,
d. Stump pressures severe stenosis, or prior ischemic vascular disease may
e. Electroencephalography be at increased risk and should receive special attention
f. Cerebral infrared oximetery to neck position in the perioperative period.5 Another
Step 6 Arteriotomy consequence of hyperextension is loss of the normal
a. Longitudinal orientation of the neurovascular structures in the
b. Everson technique neck.
Step 7 Endarterectomy Grade 1 complication
Step 8 Arteriotomy closure
a. Primary closure Prevention
b. Patch closure Careful positioning by the operating surgeon is of par-
Step 9 Wound closure amount importance. A thin roll should be placed under
the shoulders posteriorly. The head should be sup-
ported so as to not hang free and/or move during the
OPERATIVE PROCEDURE
procedure and turned carefully away from the operative
side. The operating room table should be placed in
Patient Positioning
slightly reversed Trendelenburg position and tilted
During CEA, the patient assumes a supine position with slightly away from the operative side to allow adequate
extension of the neck and contralateral rotation of the distal exposure.
 58 CAROTID ENDARTERECTOMY 587

Skin Incision
The length of the skin incision is often governed by the
morphology of the neck. A vertical skin incision extending
from the mastoid process to just above the sternoclavicu-
lar junction coursing along the anteromedial margin of
the sternocleidomastoid muscle represents the classic skin
incision utilized during exposure of the cervical carotid
artery (Fig. 581). Preprocedure duplex-assisted localiza-
tion of the carotid bifurcation may be used in order to
limit the length of the traditional skin incision to one that
may be more esthetically pleasing.6 Alternatively, a trans-
verse cervical incision made along Langers lines may be
used to gain access to the carotid artery. There is no
demonstrable difference in results when comparing the
longitudinal and the transverse incisions with similar ef-
cacy and incidence of cranial nerve decits.7

Limited Exposure
Consequence
Inadequate surgical exposure leading to incomplete
hemostasis and inappropriate management of the target
lesion are primary concerns when the surgical eld is
limited by the length of the skin incision. In patients
with high bifurcations and otherwise challenging ana-
tomy, an abbreviated incision may render the patient
at increased risk for intraoperative complication (Fig. Figure 581 Classic vertical skin incision.
582).
Grade 1 complication
Repair
Additional exposure can be obtained by extension of
the incision. Distal exposure is most commonly the

Figure 582 Carotid kink: example of challenging anatomy for exposure.

 588 SECTION X: VASCULAR SURGERY

problem. Care must be taken not to violate the sub-

stance of the parotid gland during this maneuver so as
to avoid injury to the facial nerve or create a sialocuta-
neous stula. Subluxation of the mandible can also aid
in very high distal exposure.

Prevention
Whereas preoperative duplex localization may facilitate
identication of the carotid bifurcation prior to skin
incision, these incisions may necessitate the use of
excessive amounts of traction in order to adequately
mobilize the distal internal carotid artery. Ideally, ade-
quate exposure should include the diseased portion of
the common and internal carotid arteries as well as a
region on the normal-appearing distal internal carotid
artery where vascular clamps may be applied. By com-
promising adequate exposure, the operator may experi-
ence difculty securing an adequate dissection endpoint
or may cause inadvertent neurovascular injury, leading
to increased patient morbidity.

Dissection and Exposure of the Carotid Artery

The skin incision is deepened through to the platysma
muscle, and the dissection is carried along the anterome-
dial border of the sternocleidomastoid muscle until the
carotid sheath is reached. Division of the facial vein allows
lateral retraction of the internal jugular vein and visualiza- Figure 583 Intraoperative dissection with vagus nerve (arrow).
tion of the carotid artery. The vagus nerve should be
identied as it courses deep and posterolateral to the
common and internal carotid arteries (Fig. 583). In a
small subset of patients, the vagus nerve may assume an
anterior position within the carotid sheath. This must be
recognized and the nerve carefully retracted to complete
the arterial exposure. During the arterial dissection,
caution should be taken to avoid manipulation of the
vessels by dissecting the patient away form the artery.
Mobilization of the internal carotid artery should be
extended distally just beyond the region of disease. Anti-
coagulation is administered prior to obtaining proximal
and distal arterial control, beginning with the distal inter-
nal carotid artery, followed by the common and external
carotid arteries.
Figure 584 Intraoperative dissection with carotid body
(arrow).

Perturbation of the Carotid Baroreceptor

Consequence
The carotid sinus region is an important baroreceptor
area involved in blood pressure regulation.8 During
dissection of the carotid artery, caution should be exer-
cised to avoid disruption of the carotid sinus nerves
(Fig. 584). Sinus bradycardia and hypotension may
occur owing to baroreceptor stimulation with the pos-
sibility of a new setpoint established in the periopera-
tive period.
Grade 1 complication
Repair
Inject the carotid bulb or control hemodynamic changes
with intravenous medications.
Prevention
The efcacy of prophylactic treatment with local anes-
thetic remains controversial. Maher and coworkers9
showed that injection of lidocaine into the carotid sinus
at the time of CEA is not associated with a signicant
improvement in any hemodynamic factor.9 Al-Rawi
and colleagues10 also questioned whether application of

a local anesthetic in the region of the carotid sinus
could simulate denervation, thereby validating a neural
basis for baroreceptor denervation. They concluded
that the baroreceptor response could be abolished by
the application of local anesthesia to the carotid sinus
and recommended selective usage in patients demon-
strating severe sinus sensitivity during CEA.
Cranial Nerve Injury
Most nerve injuries that occur during CEA are associated
with retraction and are usually self-limiting. In order to
minimize the risk of permanent injury, a thorough under-
standing of the neurovascular anatomy in the vicinity of
the carotid artery is mandatory. In the NASCET and
ACAS trials, the incidence of cranial nerve injury was
8.6%2 and 4.9%,3 respectively. Both studies showed com-
plete resolution of symptoms in the overwhelming major-
ity of their respective participants.
Vagus Nerve Injury
Consequence
The anatomic location of the vagal trunk may vary
because approximately 5% of patients may present with
a nerve lying anterior to the common carotid artery.
Complete vagal transection or ipsilateral recurrent
nerve injury results in hoarseness and vocal cord para-
lysis. Other vagal branches, which are susceptible to
injury, include the superior laryngeal and recurrent
laryngeal nerves. The superior laryngeal nerve courses
posteriorly and just superior to the carotid bifurcation
in a tangential plane adjacent to the superior thyroid
artery. Injury results in voice fatigue and an inability to
reach high-pitched notes. Damage to its internal,
sensory, branch may result in aspiration due to a loss
of sensory input to the supraglottic mucosa of the
larynx.
Grade 4 complication
Repair
Ipsilateral nerve injury may go undetected or produce
mild postoperative symptomatology. In the published
literature, the reported frequency of nerve injury
ranges between 3% and 23%.11 Whenever these inju-
ries are suspected, close follow-up and direct laryn-
goscopy should be used to further clarify the degree
of impediment, especially if a contralateral procedure
is contemplated.
Prevention
Careful dissection in the carotid sheath while gaining
access to the artery with awareness of the anterior vagus
anomaly.
Hypoglossal Nerve Injury
Consequence
Upon exiting the skull, the hypoglossal nerve descends
posterior to the internal and external carotid arteries
58 CAROTID ENDARTERECTOMY 589
Figure 585 Intraoperative dissection with hypoglossal nerve
(arrows).
before coursing in an oblique fashion anteriorly and
medially to provide motor innervations to the tongue
(Fig. 585). Injury to this structure results in ipsilateral
tongue deviation. Dysarthria and biting of the tongue
have been described in cases of profound dysfunction.11
Exposure of a high-lying plaque in the internal carotid
artery often necessitates cephalad retraction, which may
result in undue tension being placed on the nerve.
Neuropraxia results from such traction injuries and
may lead to difculty with speech, mastication, and
swallowing.
Grade 4 complication
Repair
If an injury to the hypoglossal nerve is recognized
intraoperatively, direct repair should be considered
often in consultation with otolaryngology or plastic
surgery.
Prevention
Injury may be avoided by careful dissection. The hypo-
glossal can be localized by following the ansa hypo-
glossi to its junction with the main nerve. The ansa may
be ligated along with small vessels providing arterial
supply and the venous drainage from the sternocleido-
mastoid muscle to mobilize the hypoglossal nerve,
allowing distal exposure of the internal carotid artery.12
Bilateral nerve injury may result in upper airway obstruc-
tion and death.
Marginal Mandibular Nerve Injury
Consequence
This supercial branch of the facial nerve exits from the
parotid gland to supply motor innervations to the angle
of the mouth. Its usual course is along the inferior
ramus of the mandible, but it can be found in more
distal locations depending on the patients anatomy or
neck position. Hyperextension with contralateral neck
rotation may lead to injury because the nerve moves
caudally when this position is assumed. Most com-
monly, injury to the marginal mandible nerve is due to
 590 SECTION X: VASCULAR SURGERY

retraction and results in drooping of the ipsilateral

lower lip.
Grade 2 complication
Repair
None, as these injuries are often self-limiting.
Prevention
Patients with high carotid bifurcations or extensive
distal internal carotid disease who require proximal
extension of the skin incision are at increased risk for
injury. In these cases, a posterior curving incision
may avoid direct nerve injury. Additional self-retaining
retractors should be positioned supercial to the pla-
tysma muscle, thus avoiding direct contact with the
nerve.

Cutaneous Innervation
Consequence
These structures are quite vulnerable to injury during
CEA. The greater auricular nerve provides sensory
innervation to the earlobe and the angle of the man-
dible. Injury results in paresthesia in the region of
innervation. The transverse cervical nerve provides
sensory innervation in the region of the anterior cervi-
cal triangle. When this nerve is injured, some men may
complain of numbness with shaving in the area of their
skin incision.
Grade 1 complication

Prevention
There are no specic therapeutic recommendations
for management of cutaneous nerve injuries. Patients
should, however, be made aware of these sensory
decits, and appropriate caution must be exercised, Figure 586 Proper vascular control of arteries prior to arteri-
for example, while shaving. These lesions are often otomy and endarterectomy.
self-limiting.

Arterial Control
Beginning with the internal carotid artery, vascular control
should be obtained in a stepwise fashion. This technique
serves to reduce the opportunity for distal embolization
of atheromatous debris. Occlusion of the common and
external carotid arteries should follow sequentially (Fig.
586).
Stroke
Consequence
Stroke, the most feared complication of CEA, may
occur owing to distal embolization of atheromatous
debris or thrombus. Stroke may also occur owing to
thrombotic occlusion of the artery. However, neuro-
logic decits are most frequently due to technical error
resulting in cerebral thromboembolization.13
Grade 4 complication
Repair
Contemporary management remains the subject of
debate. Many advocate immediate operative explo-
ration to reestablish ow; others argue that only those
patients with suspected thrombosis should be reex-
plored because this group are the only ones who may
stand to benet from operative intervention.14 Immedi-
ate duplex ultrasound imaging can determine whether
thrombosis has occurred. If the ultrasound shows
normal ow in the carotid circulation, urgent arteriog-
raphy should be considered to better dene the endar-
terectomy site and reveal intracranial abnormalities.
If imaging reveals any abnormalities, management
options include correction of any technical defects such
as intimal aps, irregularities associated with the anas-
tomotic site, removal of platelet aggregates and throm-
bus, or limited thrombectomy with caution exercised
owing to the risk of creating a carotid-cavernous sinus
stula.

Prevention
Prevention relies on adequate surgical exposure, gener-
ous arteriotomies beyond the disease endpoint, metic-
ulous endarterectomy, and patch angioplasty to reduce
technical error.15
Evaluation of Intracranial Circulation
Whereas many reports attribute postoperative cerebral
ischemia to thromboembolic events, cerebral perfusion
abnormalities are a cause of stroke during CEA. The
intracranial circulation must be assessed and managed by
either prophylactic arterial shunting or intraoperative
monitoring.
Stroke
Consequence
Stroke.
Grade 4 complication
Prevention
Whereas many surgeons routinely use interarterial
shunting, thereby avoiding the need to assess distal
perfusion, intraoperative monitoring and selective
shunting avoid the risks associated with shunt place-
ment. Numerous techniques have been described for
the evaluation, monitoring, and prevention of cerebral
malperfusion during carotid surgery.
Mechanical shunts (Sundt, Plainsboro, NJ; Javid,
Tempe, AZ; Inahara-Pruitt, Burlington, MA) are placed
in the internal carotid artery, allowing uninterrupted ow
from the distal common carotid to the proximal internal
carotid artery (Fig. 587). The major argument against
the use of shunts is the increased risk of dislodging ath-
eromatous debris and subsequent distal embolization
leading to stroke. The operation can be performed in the
awake patient allowing real-time monitoring of conscious-
ness as a surrogate marker for the adequacy of cerebral
perfusion. Stump pressures measure internal carotid artery
backpressure. This is an inferred value derived after occlu-
Figure 587 Shunt in place during endarterectomy.
58 CAROTID ENDARTERECTOMY 591
sion of the common and external carotid arteries. This
technique attempts to equate backpressure at the proximal
internal carotid artery with the cerebral perfusion pressure.
Whereas some report internal carotid artery clamping at
mean stump pressures higher than 25 mm Hg, Calligaro
and associates16 suggest that stump pressures less than
40 mm Hg systolic should be used as a threshold for
carotid shunting when the operation is performed under
general anesthesia. In patients with a previous history of
stroke or in those with uctuating systolic blood pressures,
stump pressures may not be reliable. Electroencephalog-
raphy is a noninvasive neuromonitoring technique. It cor-
relates neuronal dysfunction, as seen with cerebral
ischemia, as changes in electrical frequency. A diminution
in amplitude on electroencephalographic tracings is
observed during times of cerebral ischemia. Criticisms
offered include the need for continuous monitoring,
expert interpretation, and increased cost. Notwithstand-
ing, its use has been well established in the literature.17
Cerebral infrared oximetery is an indirect method used to
measure brain oxygen tension. It uses near-infrared spec-
troscopy through the scalp and skull for continuous non-
invasive monitoring of cerebral oxygen saturation (rSO2).18
During CEA, changes in cerebral oxygen saturation may
serve as a monitor of oxygenation trends. With carotid
cross-clamping, however, an absolute value cannot be
recommended.
Arteriotomy
There are two types of incisions commonly used during
CEA: the longitudinal and the oblique arteriotomies. The
longitudinal incision begins at the posterolateral aspect of
the distal common carotid artery and extends into the
proximal internal carotid artery to include the region of
disease. The length of this incision depends on the extent
of disease. An oblique arteriotomy is used when the ever-
sion technique is contemplated for exposure of the inter-
nal carotid artery. This incision is made in an oblique plane
though the junction of the internal and common carotid
arteries.
Arterial Injury
Consequence
Arterial injury may occur secondary to inadvertent
damage to the back wall of the carotid artery.
Grade 2 complication
Repair
Standard arterial repair. Should injury occur, primary
repair with interrupted double-armed Prolene sutures
is indicated.
Prevention
It is important to maintain a bloodless eld as the
arteriotomy is lengthened under direct visualization.
These injuries may be avoided if complete vascular
control is obtained prior to arteriotomy.
 592 SECTION X: VASCULAR SURGERY
Figure 588 Shunt in place and arrows show the endpoint
of plaque where the dissection plane will be developed for
endarterectomy.
Figure 589 Completion endarterectomy with all plaque and
medial bers removed from the wall of the carotid artery.
Endarterectomy
Removal of atheromatous debris from the internal carotid
artery should be done in a careful and methodical fashion.
A dissection plane is developed, either in the common
carotid artery or at the level of the endpoint in the distal
internal carotid, that ensures the proper plane. This plane
is established between the diseased intima and the circular
bers of the arterial media19 (Fig. 588). The plaque is
removed and can be divided if necessary in an area where
there is a smooth transition to normal-appearing intima.
Tacking sutures are required in 25% to 30% of cases to
ensure a smooth endpoint that does not lift up when
prograde arterial ow is established. Residual plaque
involving the external carotid artery is removed using the
eversion technique. Great care must be taken to remove
all residual medial bers from the endarterectomy surface
(Fig. 589).
When eversion CEA is chosen, an oblique incision is
used, and the endarterectomy endpoint is achieved in a
similar fashion. First, the proximal internal carotid artery
is transected. A dissection plane is established in the tran-
sected internal carotid artery, followed by gentle peeling
away of the remaining media and adventitia from the
atheroma until an endpoint is reached.
High Carotid Bifurcation
Consequence
Need for additional distal exposure.
Grade 1 complication
Repair
One of the current indications for carotid artery stent-
ing is a surgically inaccessible lesion; those appearing at
or above C2 or inferior to the clavicle are considered
at high surgical risk and may be treated with catheter-
based endovascular techniques.20 Adjunctive techniques
used to gain access to distal lesions may include division
of the posterior belly of the digastric muscle and sub-
luxation of the mandible, which may provide an addi-
tional 1.5 cm of distal exposure.
Difcult Endpoint
Consequence
Need for additional distal exposure or extended arteri-
otomy to safely perform the CEA.
Grade 1 complication
Prevention
Selecting the proper dissection plane is crucial to estab-
lishing a smooth distal transition point. The ideal plane
is achieved when there is a gradual feathering of the
atheromatous intima/media from the remaining artery.
In some instances, this plane may be illusive, if not
impossible, to establish owing to plaque morphology,
which may include ruptured or ulcerated debris with
and without thrombus. In these instances, tacking
sutures may be necessary in order to secure any step-off
created during dissection and to minimize the risk of
distal propagation of the dissection plane.
Patch Angioplasty
The efcacy of patch angioplasty for arteriotomy closure
after CEA is well established in the literature. Patch
closure has been demonstrated to be superior to primary
closure in prospective randomized comparisons. AbuRahma
and colleagues21 reported lower incidence of perioperative
morbidity; stroke, early restenosis, and acute postopera-
tive thrombosis when patch closure was utilized. In an
analysis of patch angioplasty, Bond and coworkers22
showed no obvious differences in the risk of stroke or
death in patients receiving synthetic versus venous
patches.22 Commonly used prosthetic materials include

Figure 5810 Patch angioplasty with Dacron patch (above) and
vein patch (below).
autogenous vein, polytetrauoroethylene (PTFE), Dacron,
and bovine pericardium (Fig. 5810).
Long Arteriotomy
Consequence
Suture line folds and kinks.
Grade 3 complication
Repair
Repeat anastomosis properly.
Prevention
Patch angioplasty should be applied in a manner that
avoids suture line folds and kinks. The length of the
arteriotomy should be limited to that which is necessary
to safely remove the endarterectomized plaque burden.
Long arteriotomies may cause suture line kinking and
subsequent disruption of ow patterns. Suture line
irregularities may also result in generation and adhesion
of microthrombi, leading to an increased incidence of
thromboembolism.
Suture Line Bleeding
Consequence
Most frequently associated with PTFE prosthetic
patches and suboptimal surgical technique.
Grade 3 complication
Repair
Careful anastomotic technique.
Prevention
Bleeding may be successfully treated with the applica-
tion of topical hemostatic agents. In the management
58 CAROTID ENDARTERECTOMY 593
of suture line bleeding, attention to blood pressure
control cannot be overemphasized.
Wound Closure
Hemorrhage
Consequence
Systemic heparinization and widespread usage of
antiplatelet agents singularly or in combination may
contribute to incomplete hemostasis and hematoma
formation in patients undergoing CEA. Hematomas
may be benign or potentially life threatening if airway
compromise ensues.
Grade 4 complication
Repair
Careful surgical hemostasis. Surgical reexploration and
evacuation of symptomatic hematomas should always
be considered. The incision should be reopened in the
operating room, if possible, where airway management
is critical. Consideration should be given to tracheos-
tomy at the time in the setting of a large hematoma
and subsequent neck tissue edema.
Prevention
Whereas most surgeons do not reverse systemic antico-
agulation because of the risk of potentially deleterious
neurologic events, there is no substitute for good sur-
gical technique. To reduce the potential for periopera-
tive bleeding and subsequent hematoma formation,
blood pressure control and utilization of temporary
suction drains are adjuncts toward reducing the mor-
bidity associated with hematoma formation.
CAROTID STENTSUPPORTED
ANGIOPLASTY
Application of minimally invasive endovascular tech-
niques to carotid artery disease represents an alternative
management option in the treatment of the extracranial
internal carotid artery. Carotid artery stenting with cere-
bral protection has emerged as an alternative for some
patients possessing signicant extracranial carotid stenosis
but who are considered at increased surgical risk. During
this procedure, access to the carotid artery is obtained
percutaneously through a puncture site in the femoral
artery. Under direct visualization, guidewires and cathe-
ters are used to negotiate the aortic arch and to traverse
the internal carotid artery. An appropriately sized metal
stent is introduced and deployed across the diseased
portion of the artery, excluding this region from the cir-
culating blood ow, thus creating a new unobstructed
lumen. Although this procedure is performed while the
patient is awake, both groups receive similar postproce-
dure monitoring.
There is a large amount of enthusiasm for carotid stent
supported angioplasty often supported by physicians who
 594 SECTION X: VASCULAR SURGERY
have no prior experience in the evaluation, treatment, or
follow-up of patients with extracranial cerebrovascular
disease. The same principles crucial to carotid surgery
certainly apply to carotid intervention: careful patient
evaluation and selection, specialized clinical training and
practice, and careful follow-up and outcomes analysis.
Interventional techniques for carotid therapy continue to
develop, although typically they are compared with the
most unfavorable gures available in the medical literature
for CEA. There are several published series with over 100
consecutive cases of elective CEA or statewide registries
that demonstrate perioperative stroke rates less than
3%.23,24 There are surgical series with acute stroke rates less
than 1% and 5-year follow-up documenting lower than 1%
ipsilateral stroke rate per year during follow-up.25 Whereas
proponents of interventional therapies are quick to note
cranial nerve palsy, they fail to note that this small group
of patients usually experiences only a very mild and
transient palsy from operative nerve retraction and
protection.
The case for endovascular approaches to coronary
occlusive disease or aortic aneurysms is far more compel-
ling because the open surgical alternative is a more inva-
sive and morbid option. This is not the case for carotid
intervention. Carotid surgery is less invasive with respect
to the diseased vascular tissue manipulated than is the
transfemoral approach. Time to discharge and intensive
care unit stay are often less for carotid endarterectomy
than for carotid stenting. The cost of CEA is stable
and low, whereas the costs associated with carotid stent-
ing continue to grow with the addition of distal protec-
tion devices and the advent of drug-coated stent
technology.
One must also consider the complications unique to a
remote approach to the carotid bifurcation. These include
femoral access site complications, lower extremity isch-
emic and embolic events, renal and visceral embolic events,
cerebrovascular emboli via the nonoperated carotid and
vertebral vessels, and the arrhythmias induced by stenting
the baroreceptor at the carotid bifurcation. These compli-
cations are rarely reported because they are unique to
carotid stenting and are, therefore, not characterized in
the literature of CEA, which is used as the predicate for
carotid stenting. Stenting of the baroreceptor at the
carotid bifurcation alone results in a signicant incidence
of bradycardia requiring intravenous medications and
intensive care unit admission. Indeed, most series have a
higher rate of intensive care unit admission and multiday
admission for stenting than is typical for CEA. The primary
method of intervention (i.e., dilation and plaque disrup-
tion) produces emboli known to be responsible for cere-
bral events in patients with carotid bifurcation disease.
Studies with transcranial Doppler have documented an
eightfold increase in emboli during angioplasty and stent-
ing procedures versus CEA.26 There has been a prolifera-
tion of protection devices to prevent periprocedural
emboli; however, the addition of each new device and
technical aspect to the procedure adds risks and additional
cost.
The rate of restenosis also remains a long-term issue,
although in the carotid, the expectation of a low resteno-
sis rate is good: high ow, large lumen, short diameter.
However, there are factors that would affect the rate of
restenosis, such as stent design and construction (i.e.,
rigidity, cell size, metal composition), with an often tortu-
ous artery in a mobile and compressible location. We also
know that stent apposition is often poor at a bifurcation
where there is a sudden and dramatic change in lumen
diameter (common carotid to the internal carotid). There
is well-recognized restenosis at the end of stents (edge
effect) that has not been characterized in the distal
internal carotid near the skull base. When restenosis
occurs, the options can be limited compared with options
for restenosis after CEA. Repeat interventional therapy
involves attempts at redilation with additional stenting.
Surgical exposure requires a more extensive exposure of
the carotid vasculature, particularly the more difcult
cephalad portion near the skull base.27
SUMMARY
CEA is one of the most highly scrutinized, studied, and
ultimately successful operative procedures available. At
this time, carotid stenting is most applicable to patients
with higher risk factors for surgical exposure of the carotid
(e.g., prior radiation, prior carotid surgery, adjacent
stomas, skull base lesions). Clinical trials in groups without
those risk factors will ultimately determine the role of
stenting in those patients. Other distinct patient groups
will likely be delineated as reasonable candidates for
primary carotid stenting but we are also likely to nd those
who are at distinctly higher risk for carotid stenting (e.g.,
tortuous carotids, bulky irregular lesions, longer lesions,
certain calcic lesions). The efcacy of CEA in stroke
prevention is well established in the literature. A thorough
understanding of the local anatomy, anatomic variances,
meticulous surgical technique, and innovations in intra-
operative monitoring will allow CEA to preserve its posi-
tion as the reigning gold standard in the treatment of
carotid disease.
REFERENCES
1. American Heart Association. Heart and stroke facts.
Available at http://www.americanheart.org (assess veried
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2. North American Symptomatic Carotid Endarterectomy
Trial Collaborators. Benecial effects of carotid endarter-
ectomy in symptomatic patients with high-grade carotid
stenosis. N Engl J Med 1991;325:445453.
3. Endarterectomy for asymptomatic carotid artery stenosis.
Executive Committee for the Asymptomatic Carotid
Atherosclerosis Study. JAMA 1995;273:14211428.

4. Department of Health and Human Services, Center for
Medicare and Medicaid Services. Summary report, ICD-9-
CM Coordination and Maintenance Committee, April
12, 2004. Available at http://www.cms.hhs.gov/
paymentsystems/icd9 (access veried 1/25/07).
5. Weintraub MI, Khoury A. Cerebral hemodynamic changes
induced by simulated tracheal intubation: a possible role
in perioperative stroke?: magnetic resonance angiography
and ow analysis in 160 cases. Stroke 1998;29:1644
1649.
6. Ascher E, Hingorani A, Marks N, et al. Mini skin incision
for carotid endarterectomy (CEA): a new and safe
alternative to the standard approach. J Vasc Surg 2005;42:
10891093.
7. Skillman JJ, Kent KC, Anninos E. Do neck incisions
inuence nerve decits after carotid endarterectomy? Arch
Surg 1994;129:748752.
8. Eckberg DL, Sleight P. Human baroreexes in health and
disease. In Baroreex Anatomy. Oxford, England:
Clarendon, 1992; pp 1931.
9. Maher CO, Wetjen NM, Friedman JA, et al: Intraopera-
tive lidocaine injection into the carotid sinus during
endarterectomy. J Neurosurg 2002;97:8083.
10. Al-Rawi PG, Sigaudo-Roussel D, Gaunt ME. Effect of
lignocaine injection in carotid sinus on baroreceptor
sensitivity during carotid endarterectomy. J Vasc Surg
2004;39:12881294.
11. Schauber MD, Fontenelle LJ, Solomon JW, et al.
Cranial/cervical nerve dysfunction after carotid endarter-
ectomy. J Vasc Surg 1997;25:481487.
12. Knight FW, Yeager RM, Morris DM. Cranial nerve
injuries during carotid endarterectomy. Am J Surg 1987;
154:529532.
13. Riles TS, Imparato AM, Jacobowitz GR, et al. The cause
of perioperative stroke after carotid endarterectomy.
J Vasc Surg 1994;19:206216.
14. Aburahma AF, Robinson PA, Short YS. Management
options for post carotid endarterectomy stroke. J Cardio-
vasc Surg 1996;37:331336.
15. Rockman CB, Jacobowitz GR, Lamparello PJ. Immediate
reexploration for the perioperative neurologic event after
carotid endarterectomy: is it worthwile? J Vasc Surg 2000;
32:10621070.
16. Calligaro KD, Dougherty MJ. Correlation of carotid
stump pressure and neurologic changes during 474 carotid
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endarterectomies performed in awake patients. J Vasc Surg
2005;42:684689.
17. Reuter NP, Charette SD, Sticca RP. Cerebral protection
during carotid endarterectomy. Am J Surg 2004;188:772
777.
18. Casati A, Spreaco E, Putzu M, et al. New technology for
noninvasive brain monitoring: continuous cerebral
oximetry. Minerva Anestesiol 2006;72:605625.
19. Moore WS, Quiones-Boldrich WJ, Krupski WC. Indica-
tions, surgical technique and results for repair of extracra-
nial occlusive lesions. In Rutherford RB (ed): Vascular
Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005; pp
17891822.
20. Yadav JS, Wholey MH, Kuntz RE, et al, and the Stenting
and Angioplasty with Protection in Patients at High Risk
for Endarterectomy Investigators. Protected carotid artery
stenting versus endarterectomy in high-risk patients.
N Engl J Med 2004;351:14931501.
21. AbuRahma AF, Khan JH, Robinson PA, et al. Prospective
randomized trial of carotid endarterectomy with primary
closure and patch angioplasty with saphenous vein, jugular
vein, and polytetrauoroethylene: perioperative (30-day)
results. J Vasc Surg 1996;24:9981007.
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23. Yates GN, Bergamini TM, George SM, et al. Carotid
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59
Aortic Surgery
John Byrne, MB and R. Clement Darling III, MD
INTRODUCTION
Aortic reconstruction is an index operation, one whose
outcome is used to compare surgeons and centers. With
validated tools, the surgeon can be made the statistical
variable.1 In an era of ranking and league tables, there are
obvious implications. For patients, the implications are
more critical. But aortic surgery is difcult. Even in the
best hands, complications occur. Despite the advent of
endovascular procedures, there are still those who are
unsuitable for, or unwilling to undergo, stent grafting,
and even this procedure is not without complications.
Infrarenal aortic surgery can be divided into three areas:
(1) aortobifemoral bypass for occlusive disease, (2) elec-
tive abdominal aortic aneurysm (AAA) repair, and (3)
repair of ruptured AAAs. There are two approaches to the
aorta: transabdominal and retroperitoneal. In this chapter,
we describe how we do aortic surgery at Albany Medical
Center, by the retroperitoneal approach. We share the
strategies we use to minimize complications. More perti-
nently, we describe what we do when complications arise.
Young surgeons will read of these and doubt their rele-
vance. Older surgeons will read them and empathize. In
the surgical literature, papers detailing success outnumber
those documenting failure. Therefore, much of this
chapter is based on our own complications or dealing with
the aftermath of others.
We use the retroperitoneal approach for all aortic repairs
including ruptured aneurysms.2 We accept this is a minor-
ity practice. Most aortic surgery is performed via a trans-
peritoneal approach. Despite our bias, we still employ the
transabdominal approach when other pathology needs to
be addressed at the same operation. However, before
describing techniques in detail, it is worthwhile addressing
some recurring arguments.
CONTINUING CONTROVERSIES
End-to-Side or End-to-End Anastomosis in
Aortobifemoral Bypass? (Fig. 591)
In Europe, the end-to-side anastomosis is favored. In
North America, end-to-end is preferred. It is argued that
an end-to-end anastomosis is easier to perform. It is more
anatomic and avoids competitive ow between the graft
and the native arteries. Therefore, it ought to have better
patency and carry low risk for duodenal stulas. The argu-
ment in favor of the end-to-side approach is that it
preserves anterograde ow to the pelvic viscera, and in
the event of graft occlusion, the patients status reverts
to that prior to surgery rather than being profoundly
worse, as might be the case if an end-to-end anastomosis
occluded.
Both opinions steer clear of the facts. There have
been randomized, controlled studies comparing both
approaches. An initial study of 79 patients in 1982 from
Chicago showed small but signicant advantages for end-
to-end anastomoses over end-to-side.3 However, a larger
study from Becquemins group4 in Paris in 1990 of 158
patients refuted this, as did a study from Toronto of 120
patients.5 The most impressive statistic, however, was just
how durable aortic bypasses were, regardless of the means
used to sew them together. Actuarial primary 5-year
patency rates were 90%. Secondary patency rates were
98%. So there is really little to choose between either
approach. The best advice came from the French who
suggested that as we could not nd any difference
between the results in the two groups, we suggest choos-
ing the simplest procedure which maintains adequate
pelvic and colonic blood supply, according to angiographic
ndings.
Polytetrauoroethylene or Dacron?
Most centers use Dacron for aortic surgery. These grafts
are either knitted collagen-coated or knitted gelatin-
coated. Woven Dacron grafts are not widely used now.
The alternative is expanded stretch polytetrauoroethyl-
ene (PTFE). Since 1991, we have used stretch Gore-Tex
grafts for all our aortic anastomoses. Concerns about
needle hole bleeding are unfounded. We nd that stretch
PTFE has handling characteristics that are at least as good
as those of Dacron. Theoretically, PTFE is also less likely
to dilate over time.
Again, there are good randomized, controlled data
comparing the various materials. A well-performed pro-
spective study from Cornell in 1995 compared PTFE and
 598 SECTION X: VASCULAR SURGERY
Figure 591 End-to-side aortobifemoral bypass with Dacron.
Dacron and showed no difference in outcomes.6 A
large multicenter, prospective, randomized, controlled
trial of gelatin-impregnated Dacron, collagen-impregnated
Dacron, and PTFE involving 315 patients from Vienna in
2001 also failed to show a difference.7
Clamp the Aneurysm Neck or the Common
Iliacs First?
The sequence of applying clamps to AAAs has exercised
some of the better minds in vascular surgery. Whether to
clamp the proximal neck prior to the iliacs or vice versa?
At the outset, we should declare an interestwe always
clamp the iliacs rst in elective cases.
There are two questions: (1) Does clamping the iliacs
rst protect against emboli traveling down the leg?
(2) Does clamping the aortic neck rst protect against
embolization to the renal and visceral arteries from the
aortic sac? A study from Leicester in the United Kingdom
in 2004 examined the rst question by comparing the rate
of embolization down the supercial femoral arteries of
patients undergoing aortic surgery using a transcranial
Doppler.8 They showed no difference between the aorta-
rst group and the iliacs-rst group. The second ques- were equivocal. In 1990, the Massachusetts General Hos-
tion was most recently addressed by the Monteore
Medical Center study in 1999.9 Although this was an
animal study in nonatherosclerotic aortas, they suggested
that clamping the aorta rst could protect against em-
bolization to the renal arteries.
Retroperitoneal or Transperitoneal? (Fig. 592)
Why do we favor the retroperitoneal approach? Aside from
the theoretical considerations of quicker return of bowel
and respiratory function, we feel it is more versatile. It
provides easy access to the left common iliac and internal
iliac arteries. Once mastered, it also provides easier access
to the left renal artery and the aortic neck. It avoids the
left renal vein, which is reected anteriorly out of the
operative eld, and also avoids the gonadal veins, which
Figure 592 Transperitoneal exposure of an abdominal aortic
aneurysm (AAA).
can be a problem when the aorta is approached from the
front. Many of the aneurysm repairs we perform are those
rejected for endovascular repair and are really juxtarenal
or suprarenal aneurysms. Suprarenal clamping, therefore,
becomes an important issue. Once the lumbar branch of
the left renal vein is ligated and the peritoneal contents
and kidney are retracted cephalad and medial, access to
the infradiaphragmatic aorta can easily be obtained by
incising the left crus. This allows the proximal aortic
clamps to be placed above, below, or between the renals
as well as on the supraceliac aorta. However, the proce-
dure has a denite learning curve. Using a left ank inci-
sion, access to the right common and internal iliac arteries
is difcult and, in many cases, impossible. To access these
vessels, we perform a separate right counterincision. Reim-
plantation or bypass of the right renal artery, when
required, is also technically difcult but can be performed
with experience.10 The retroperitoneal approach is more
time-consuming when performing a straightforward infra-
renal tube graft. The areolar tissue around the aorta is also
vascular and can result in blood loss that is usually not
encountered in the conventional approach.
There are randomized, controlled data. Initial reports
pital group showed little difference in outcomes between
the two techniques.11 However, in 1995, Sicard and
coworkers12 reported the results of a randomized, con-
trolled trial of 145 patients. Whereas there was no differ-
ence in mortality rates, the retroperitoneal approach was
associated with fewer postoperative complications, shorter
hospital and intensive care stays in the hospital, and lower
cost. In 1999, Kirby and colleagues13 from Atlanta reported
on 92 high-risk American Society of Anesthesiologists
Class IV (ASA IV) patients randomized to either transab-
dominal or retroperitoneal aortic repair. Complications
were signicantly lower in the retroperitoneal group. So,
it would seem that proponents of the retroperitoneal
approach, including ourselves, are vindicated by the
literature. Unfortunately, in the interests of balance, we
must also include Lawrence-Brown and associates trial
 59 AORTIC SURGERY 599

from Perth in 199714 involving 100 patients that showed

no difference at all between the two techniques. In the
end, it seems that either approach is justied as long as
outcomes are acceptable and pitfalls avoided.

Aortobifemoral Bypass
by the Retroperitoneal
Approach
INDICATIONS

Severe aortoiliac occlusive disease resulting in Figure 593 Patient positioning for an aortobifemoral bypass
with the incisions marked.
Limiting claudication in a young patient
Rest pain or nonhealing wounds
Leriches syndrome

In higher-risk patients unsuitable for endovascular proce-

dures, consideration should be given to iliofemoral bypass
or extra-anatomic bypasses: femorofemoral, iliofemoral
crossover, or axillofemoral bypass.

OPERATIVE STEPS

The left ank approach was rst described by Williams and

coworkers at Johns Hopkins in 1980.15 They described an
incision through the 11th intercostal space with division
of the left crus of the diaphragm. Our technique is based
on this original description. We do not use the so-called
anterior retroperitoneal approach of Schumacker, whereby
the retroperitoneal space is developed using a vertical
midline incision.16 Figure 594 Skin markings for an aortobifemoral bypass.

Step 1 Patient positioning

Step 2 Exposure of both femoral arteries shoulders angled at 45o. The trunk is supported in this
Step 3 Left ank skin incision position using a beanbag that extends from the hips to
Step 4 Reection of peritoneum and creation of retro- the shoulder. This is made rm once the patients position
peritoneal space is correct. Care is taken to place the hips over the break
Step 5 Dissection of aorta in the table. The left hip is exed, and the knee and lower
Step 6 Fashioning of proximal anastomosis leg are supported on a beanbag. The right hip is externally
Step 7 Tunneling of graft limbs and performing femoral rotated and the knee is exed (frog-legged). The table is
anastomoses broken. An indelible marker is used to draw the incision.
Step 8 Inspection of peritoneal cavity and closure of The landmarks are the 10th intercostal space (just above
ank incision the last oating rib) and a point midway between the
symphysis pubis and the umbilicus along the lateral margin
of the rectus abdominis muscle.
OPERATIVE PROCEDURE
Incision Too Low
Patient Positioning (Figs. 593 and 594)
Consequence
This may seem pedantic. However, poor positioning for Placing an incision too low makes access to the aortic
the retroperitoneal approach can transform a relatively neck difcult, if not impossible. Time spent marking
straightforward operation into a miserable experience for the incision is time well spent, especially when learning
all concerned. The patient is placed in the left lateral posi- this approach.
tion with the hips angled at 30o to the horizontal and the Grade 1 complication
 600 SECTION X: VASCULAR SURGERY
Figure 595 Exposure of both femoral arteries followed by
exposure of the aorta.
Repair
Taking the incision more posterior will allow for more
upward exposure.
Prevention
Attention to anatomic landmarks and careful marking
of the incisions preoperatively.
Exposure of Both Femoral Arteries
(Fig. 595; see also Fig. 594)
We also mark the position of the femoral arteries on the
skin prior to draping. The exaggerated position of the
patient for this procedure can obscure the normal surface
anatomy and result in unnecessarily large groin incisions.
We perform a node-sparing femoral incision to reduce the
risk of postoperative lymphatic stulas.
Lymphatic Leak
Consequence
Many lymphatic stulas are self-limiting and eventually
seal spontaneously. However, particularly persistent
leaks may require intervention.
Grade 2/3 complication
Repair
Persistent leaks can be explored. We inject disulfan blue
into the lower thigh just prior to surgery. This enables
us to identify the leak. We then oversew the leaking
lymphatic with a Vicryl suture.
Prevention
Careful placement of the skin incision. The position of
the incision is the junction of the lateral two thirds and
the medial one third of the inguinal ligament (identi-
ed by the pubic tubercle medially and the anterior
superior iliac spine laterally). We identify the supercial
femoral fascia and then dissect medially, lifting the
inguinal nodes medially until the common femoral
artery is encountered. The supercial epigastric artery
is frequently encountered coming anteriorly off the
common femoral artery 1 to 2 cm below the inguinal
ligament.
Femoral Neuropathy
Consequence
The femoral nerve supplies sensory branches to the skin
of the anterior thigh and also via the saphenous nerve
to the lateral aspect of the lower leg. More importantly,
it also supplies motor branches to the quadriceps
femoris. Damage results in signicant loss of knee
exion.
Grade 4 complication
Prevention
Careful placement of the skin incision. The position of
the incision is as already described. The femoral nerve
has already divided into several branches at this level.
All major branches are lateral to the artery and deep to
the lymph nodes. Judicious use of electrocautery at this
level will also reduce the risk of inadvertent nerve
injury.
Left Flank Skin Incision (See Fig. 595)
The skin is incised and the subcutaneous fat divided using
electrocautery. The ank muscles (external oblique, inter-
nal oblique, and transversus abdominis) and the transver-
salis fascia are divided using electrocautery to minimize
bleeding. The peritoneum is exposed laterally. Medially,
it is fused to the overlying muscle layers and can be more
easily breached. All efforts are made to gently dissect the
peritoneum off the overlying muscle and the tissues of
the abdominal wall without tearing it. When dividing the
muscle layers medially, the rectus sheath is not usually
divided.
A Tear in the Peritoneum
Consequence
A small opening in the peritoneum can quickly develop
into a large one with herniation of the small bowel into
the operative eld, requiring extensive manipulation of
the bowel to reduce it back into the peritoneal cavity.
This defect can then be extremely difcult to close.
Grade 1 complication
Repair
Any breach in the peritoneum can usually be repaired
with 2-0 or 3-0 Vicryl.
Prevention
Start dissecting the peritoneum laterally. Frequently,
the peritoneum is more adherent to the overlying

muscles medially. Immediately repair any small tear in
the peritoneum because, as the operation proceeds,
these can quickly develop into larger holes.
Reection of the Peritoneum and Creation of
the Retroperitoneal Space (Figs. 596 and 597)
The peritoneum usually can be swept off the underlying
adipose tissue and the lateral abdominal wall muscles fairly
easily. It is easier to sweep the peritoneum from the iliac
vessels rst and then move superiorly and laterally. The
peritoneum is swept off the psoas muscle. Next, the left
kidney is displaced anteriorly. The connective tissue strands
anchoring the peritoneum to the lateral abdominal wall
are sharply divided. Some of these are reasonably vascular
and need to be cauterized. We now position our Book-
walter retractor. Others may use an OmniTract or similar
self-retaining retraction device. At this stage, the aorta can
usually be palpated, although it will be encased in areolar
tissue. This is sharply dissected off the underlying aorta.
The left ureter is identied at this stage, although usually
it does not impinge on the operative eld.
Figure 596 The left ureter is always identied and carefully
preserved.
Figure 597 Placement of a Bookwalter retractor.
59 AORTIC SURGERY 601
Splenic Laceration
Consequence
If, at any stage during surgery, an unexplained drop in
blood pressure occurs, injury to the spleen should be
suspected.
Grade 4 complication
Repair
Usually mandates splenectomy, which can be performed
via the left ank incision.
Prevention
Careful placement of the retractors is key. We always
try to ensure that the blades of the Bookwalter retrac-
tor are angled towards the patients right shoulder and
away from the left upper quadrant of the abdomen
where the spleen lies. Thus, direct compression of the
spleen is avoided.
Duodenal Injury
Consequence
Duodenal injury.
Grade 4 complication
Repair
Duodenal injury will manifest itself by a stula several
days after surgery. Whereas the stula itself may seal
after a few days, the consequence will be an infected
graft.
Prevention
We avoid placing the blades of the retractor directly in
contact with the underlying tissues, but instead, try to
protect them with abdominal swabs. The key, though,
is awareness of the possibility of these complications.
Dissection of the Aorta
For an aortobifemoral bypass, dissection is conned to the
aorta between the inferior mesenteric artery and the renal
arteries. As well as avoiding unnecessary dissection, it also
reduces the danger of injury to the superior hypogastric
plexus with its attendant effects on sexual function in the
male. Several lumbar arteries and veins may be encoun-
tered at this level, and these are either ligated or surgically
clipped. Dissection is carried behind the aorta, and all
areolar tissue is also cleared anteriorly. In patients with a
total occlusion of the aorta to the level of the renal arter-
ies, one must clamp the aorta and both renal arteries prior
to dividing the aorta. Here, it will be necessary to dissect
the suprarenal aorta. To do this, the left crus of the dia-
phragm is divided. With more dissection, it is possible to
place a clamp around the aorta. The left renal artery
should also be readily apparent at this stage. The right
renal artery requires more dissection. With ush occlu-
sions of the aorta to the level of the renals, removal of the
plug of atheroma from the aorta has been likened to
popping the cork from a bottle of wine. This is not always
 602 SECTION X: VASCULAR SURGERY

the case. Sometimes, it can be removed only in piecemeal

fashion.
Inferior Vena Cava Injury
Consequence
Life-threatening hemorrhage.
Grade 4 complication
Repair
The traditional teaching, often forgotten in the heat of
battle, is to use two spongesticks: one proximal to the
injury and one distal. The inferior vena cava (IVC) is
then repaired using a Prolene suture. However, it is
also useful to have an experienced helper with two large
suctions who realizes the gravity of the situation. If the
posterior wall has also been penetrated, it may be nec-
essary to mobilize a segment of the IVC.
Prevention
Careful dissection is again key in this situation.
Fashioning of the Proximal Anastomosis
Following administration of heparin (usually in the range
of 3000 IU), the aorta is cross-clamped using two Fogarty
aortic clamps. The aorta is transected, and any lumbars
are sutured or clipped. The distal aorta is oversewn using
3-0 Prolene suture and the clamp removed. A bifurcated
Gore-Tex graft is brought into the operating eld and Figure 598 Tunneling of the aortic graft.
trimmed. An end-to-end anastomosis is fashioned using a
3-0 running stitch. We then position a clamp distal to the
anastomosis and check the anastomosis to ensure that it
is hemostatic. Frequently, at this stage, we place throm- the groin incisions. The tunnels are fashioned in an ana-
bin-impregnated Gelfoam around the proximal anastomo- tomic fashion, which means staying as close to the native
sis, although this is not of much help if a large leak occurs vessels as possible. The femoral anastomoses are then per-
in the proximal suture line. formed using 60 Prolene suture in a standard parachute
fashion.
Suture Line Bleed
Venous Injury
Consequence
The consequence is bleeding, often life-threatening. Consequence
Grade 1 complication The most easily injured vein is the deep circumex iliac
vein, which crosses in front of the external iliac artery
Repair approximately 2 cm above the inguinal ligament to join
Reinforce the suture line with further 3-0 Prolene the external iliac vein. To avoid this, the rst 12
sutures. Sometimes, it is more useful to use a smaller centimeters of the tunnel from the groin should be
suture such as a 4-0 or even a 5-0 for particularly completed under direct vision. If this vein is injured, it
troublesome bleeds. Some have also described, albeit can result in troublesome bleeding, which needs to be
anecdotally, placing a tube of Dacron or Gore-Tex addressed.
over the suture line in bad bleeds in which nothing else Grade 1 complication
has helped.
Repair
Prevention If the deep circumex iliac vein is injured, it needs to
Careful attention to anastomotic technique. be repaired. Often, direct suture repair is required,
although occasionally the use of large Ligaclips can be
effective.
Tunneling of Graft Limbs and Femoral
Anastomoses (Fig. 598)
Prevention
This is a blind procedure. The initial several centimeters The initial several centimeters of the tunnel from the
of the tunnels can be performed under direct vision from groin should be completed under direct vision. The

tunnel should be made as close to the native artery as
possible.
Bleeding from the Tunnel
Consequence
This can be a problem in patients in whom postopera-
tive anticoagulation needs to be reinstigated fairly
quickly such as those with prosthetic mitral valves. Very
often, it is self-limiting, but it can result in the loss of
several units of blood.
Grade 1 complication
Repair
If bleeding is noticed at the time of surgery, of course
the source of the bleeding should be found and
addressed. If found postoperatively in a stable patient
(e.g., on computed tomography [CT]), it can be
managed conservatively like most retroperitoneal
bleeds.
Prevention
See Prevention under Venous Injury, earlier.
Bowel Injury
Consequence
This is the nightmare scenario of blind tunneling. This
was reported in the 1960s,1719 but has not been admit-
ted to since.
Grade 4/5 complication
There is little choice but to deal with this in the manner
of any infected graft with explantation of the graft and
either direct reconstruction with femoral vein or by means
of bilateral axilloprofunda bypasses.
Prevention
Ensure that the tunnel remains extraperitoneal and
that, in the pelvis, the tunnel is made as posterior as
possible, avoiding inadvertent injury to the cecum on
the right or the sigmoid colon on the left.
Inspection of the Peritoneal Cavity
and Closure of the Flank Incision
Inspect the peritoneal cavity. Free blood may alert to a
splenic laceration or intra-abdominal catastrophe. Isch-
emic bowel may alert to the need for reimplantation of
the inferior mesenteric artery.
Inspect the ureter. It is usually placed under some
tension in this exposure. In older patients with less elastic
tissue, it can rupture.
Sweep the peritoneum away from the muscle layers to
prevent peritoneum (and sigmoid colon) being incorpo-
rated into the muscle closure. On at least two occasions
that the authors know of, this has occurred, resulting in
an infected graft in the rst case and a fecal stula with
need for a Hartmanns procedure in the second.
59 AORTIC SURGERY 603
Division of the Ureter
Consequence
Either inadvertent cutting of the ureter or, more likely,
a traction injury resulting in the ureter being torn apart.
A retrievable situation if recognized immediately, with
few immediate implications for the patient or the graft.
If not recognized until urine is found leaking from the
ank wound several days later, the prognosis is less
favorable, with a high risk of graft infection.
Grade 1 complication if recognized immediately,
grade 3 complication if recognized several days
postoperatively
Repair
Call for a urologist. Repair involves insertion of a
double-J stent, with suture repair of the ureter over the
stent using Vicryl suture. Alternatively, it may be neces-
sary to reimplant the ureter into the bladder or even
perform a ureteroureterostomy.
Prevention
Awareness of the condition is key. Also, it is mandatory
to inspect the ureter at the end of surgery to ensure
the left ureter is intact. This is treatable if identied in
the operating room.
Bowel Injury/Fecal Fistula
Consequence
Fecal peritonitis carries a high mortality rate. Aortic
graft infection also has a high morbidity. These two
complications in tandem, therefore, have a particularly
poor prognosis.
Grade 4/5 complication
Repair
Help will be needed from a colorectal surgeon. Usually,
the rst indication of this complication is a fecal stula
or peritonitis several days postoperatively. The patient
usually requires a Hartmanns procedure. If graft con-
tamination has occurred, the infected graft must be
removed with either in situ revascularization with
femoral vein or extra-anatomic revisualization by axil-
lofemoral bypasses.
Prevention
Closure is best performed after sweeping the perito-
neum away from the overlying muscle layers, ensuring
that good bites are taken through muscle rather than
peritoneum.
Postoperative Small Bowel Obstruction Due to
Herniation through the Posterior Sheath of the
Rectus Abdominis
Consequence
A rare complication, but one best avoided and easily
mistaken for post-operative ileus. If the posterior rectus
 604 SECTION X: VASCULAR SURGERY

sheath is opened and not adequately closed at the end differences. We tend to use bifurcated grafts in about
of surgery, small bowel can herniate through the newly 80% of our patients. Therefore, it is important to gain
formed orice and incarcerate. access to the right iliac system. We do this with a small
Grade 3 complication counterincision.
Step 1 Patient positioning
Repair
Step 2 Left ank skin incision
The incarcerated incisional hernia needs to be repaired
Step 3 Right suprainguinal incision (in case of bifur-
in the same manner as any other incisional hernia, using
cated grafts)
either primary or mesh closure.
Step 4 Reection of peritoneum and creation of retro-
peritoneal space
Prevention
Step 5 Dissection of aorta and iliacs
Awareness of the potential for this to occur and
Step 6 Clamping distally and proximally; suprarenal
scrupulous attention to abdominal wound closure.
clamp if needed
Flank Bulge Step 7 Opening of aneurysm sac
Step 8 Proximal and distal anastomoses
Consequence
Step 9 Inspection of peritoneal cavity and closure of
A minority of patients will notice a bulge in their left
ank incision
ank after their wound heals. This can be uncomfort-
able for patients. The patient may even be referred to
a general surgeon by their primary care doctor for
OPERATIVE PROCEDURE
repair of an incision hernia. This is in fact accid dener-
vated abdominal wall musculature.
Patient Positioning
Grade 2 complication
See Aortobifemoral Bypass by the Retroperitoneal
Repair
Approach, earlier.
No repair. Avoid the temptation to place a mesh deep
to the whole area. It never resolves the problem. Gar-
ments are available that will act as binders to improve Left Flank Skin Incision
the cosmetic appearance.
See Aortobifemoral Bypass by the Retroperitoneal
Prevention Approach, earlier.
Some have suggested that, by not taking the incision
beyond the costal margin, this complication may be
Right Suprainguinal Incision (In Case of
avoided.
Bifurcated Grafts) (Fig. 599)
For patients with signicant right common iliac artery
Elective AAA Repair by occlusive disease, the landing zone for the right-sided
anastomosis can be the right common femoral artery or
the Retroperitoneal the right external iliac artery. We prefer the external iliac
artery because it is more deeply placed than the common
Approach (Including femoral with less chance of lymphatic leakage and infective
complications than the femoral artery. To approach this,
Repair of Suprarenal a 4- to 5-cm transverse suprainguinal incision is made. The
external oblique aponeurosis is divided, and the internal
and Juxtarenal AAAs) oblique is also divided to approach the peritoneum. The
peritoneum is swept superiorly off the underlying external
INDICATIONS iliac artery. The other scenario is a patient with a large
right common iliac artery aneurysm. The options for
AAA larger than 5.5 cm or larger than 5.0 cm in dealing with this are
females
Symptomatic nonruptured AAAs 1. Ligating the distal common iliac from the left ank in-
Rapidly expanding aneurysms cision (see later) with a bypass onto the right external
Saccular AAAs (controversial) iliac artery. This then perfuses the right internal iliac
by retrograde ow.
2. Dissecting superiorly along the anterior wall of the ex-
OPERATIVE STEPS ternal iliac until the junction of the right internal and
external iliac arteries is encountered. The right inter-
The operative steps are very similar to those described nal iliac is then encircled with a size 1 or 0 Ethibond
for aortobifemoral bypass. However, there are several or silk suture and ligated. Pelvic blood supply is then
 59 AORTIC SURGERY 605

A
Figure 5910 Dissection of both common iliac arteries and
clamping of the left common iliac artery with a single-rubber clamp.
Note the areolar tissue encasing the AAA.

B
Figure 599 A and B, Incisions for an aortobi-iliac bypass for
aneurysmal disease and close-up of the right suprainguinal incision
for exposure of the right external iliac artery.

dependent on the left internal iliac artery, which must
be preserved.
The right external iliac is similarly ligated proximally,
and the right limb of the graft is sewn either end-to-side
or end-to-end onto it. In the case of an obese patient, the
skin incision will need to be extended to access the inter-
nal iliac artery.
Reection of the Peritoneum and Creation
of the Retroperitoneal Space
See Aortobifemoral Bypass by the Retroperitoneal
Approach, earlier (see Figs. 595 and 597).
Figure 5911 Ligation of the origin of the right common iliac
artery with nonabsorbable suture.
Dissection of the Aorta and Iliacs; Clamping
Distally and Proximally, Suprarenal Clamp if
needed; Opening of the Aneurysm Sac;
Proximal and Distal Anastomoses
(Figs. 5910 to 5921)
The left common and external iliac arteries are usually rst
encountered as the peritoneum is swept forward. With
more dissection, the right common iliac artery can also be
identied. Next, the aortic bifurcation is dissected. The
 606 SECTION X: VASCULAR SURGERY

Figure 5912 Ligation of the lumbar branch of the left renal vein. Figure 5913 Placement of a Fogarty Hydrogrip clamp across
This is one of the three markers for the aortic neck; the others the neck of the aneurysm and opening of the aortic sac.
being the left crus of the diaphragm and the left renal artery.

patient is heparinized. Clamps are placed on the common

iliacs if they are not aneurysmal.
If the left common iliac is dilated, it is easy to place
clamps on the internal and external iliacs instead. If
the right common iliac is aneurysmal, it may be possible,
with enough countertraction, to encircle the distal right
common iliac and ligate it through the left ank incision.
However, it is prudent to place a clamp on the right
external iliac before attempting to do this. Excessive trac-
tion on the right common iliac can cause embolization
down the right leg. If access cannot be obtained, then the
right external and internal iliacs should be clamped and
ligated from below via a right suprainguinal incision.
The next step is to control the aortic neck. The aorta
is identied deep to its investing areolar tissue, and dis-
section is continued cephalad. The lumbar branch of the
left renal vein is encountered and must be ligated. With
further dissection, the left renal artery will be seen reected
anteriorly. As they are encountered, the lumbar arteries
and the inferior mesenteric artery can be ligated. The aorta
needs to be freed from its surrounding areolar tissue, both
anteriorly and posteriorly. Any lumbar arteries or veins can
be ligated. A Fogarty Hydrogrip clamp is now placed
across the aorta. The aortic sac is incised and the contents
evacuated and any lumbars oversewn with 30 Prolene.
The aortic neck is transected completely to allow for an Figure 5914 The completely transected aortic neck.

Figure 5915 Sewing the Gore-Tex graft in place with 3-0
polypropylene suture using the parachute technique.
end-to-end anastomosis. Care must be taken to ensure
that a decent rim of aortic neck (at least 1 cm) is left for
the proximal anastomosis. If suprarenal control is needed,
divide the left crus of the diaphragm. This will always be
required for adequate access to the suprarenal aorta. It
may also be needed, sometimes, for access to the infrare-
nal aorta.
Distal Embolization
Consequence
This may manifest itself as atheroemboli, which appear
as punctate lesions on the toes and are often self-
limiting. Occasionally, atheroemboli may appear on the
buttocks as a consequence of embolization down the
internal iliacs. Rarely, this may manifest itself as lum-
bosacral plexopathy. If a signicant embolus has
occurred, acute leg ischemia will be the result with a
cold, pale, pulseless extremity. Untreated, the ultimate
consequence will be limb loss.
Grade 3/4 complication
Repair
Recognition that there is a problem is the most impor-
tant step, especially at the end of a long and taxing
operation. It is not enough to hope that a cold, cya-
nosed limb will start pinking up upon return to the
59 AORTIC SURGERY 607
Figure 5916 Completed anastomosis demonstrates the left
renal artery (arrow).
raried atmosphere of the recovery area. If either leg is
ischemic, it is important to ensure that there is ade-
quate ow through both iliacs in the case of a tube
graft and into the femorals in the case of a bifurcated
graft. Once adequacy of inow has been established,
the femorals should then be explored and a femoral
embolectomy performed. If adequate amounts of clot
are retrieved and the Fogarty catheter passes to the
ankle, little else may need to be done. However, on
occasion, it may also be necessary to explore the infra-
geniculate popliteal artery and perform selective embo-
lectomies of the crural vessels. This, although tiresome
at the end of a long procedure, is preferable to a major
limb amputation at a later date.
Prevention
Adequate heparinization is of course important. In the
retroperitoneal approach, the iliac clamps should be in
place before dissecting the aneurysm sac. There is more
manipulation of the sac in this approach, and therefore,
the potential for emboli is possibly greater.
Injury to the IVC or the Common Iliac Veins
Consequence
Bleeding, often life-threatening.
Grade 4 complication
 608 SECTION X: VASCULAR SURGERY

Figure 5919 Inspection of the sigmoid colon for evidence of

overt ischemia and inspection of the peritoneal cavity for intra-
abdominal bleeding.

Figure 5917 Right limb of grafttoright external iliac artery

bypass.

Figure 5920 Closure of muscles in three layers.

Figure 5918 Completed repair of AAA: aortatoright exter-

nal iliac and left common iliac bypass with Gore-Tex.

Repair
Again the two-spongestick approach is useful. As a
general rule in the retroperitoneal approach, dissection
around the right common iliac artery should be kept
to a minimum owing to the difculty in controlling
venous bleeding from the left ank incision. Remem-
ber, direct pressure on the bleeding site will contain
many problems, until denitive repair can be performed
with 3/0 or 4/0 prolene sutures. Figure 5921 Completed skin closure.

Prevention
Careful dissection. Avoid unnecessary dissection around
the right common iliac artery.
Injury to the Ureter
Consequence
See under Division of the Ureter, earlier.
Grade 1 complication if recognized, Grade 3 com-
plication if unrecognized
Repair
See under Division of the Ureter, earlier.
Prevention
See under Division of the Ureter, earlier.
Proximal Aortic Neck Falls Apart
Consequence
Bleeding, often life-threatening.
Grade 4 complication
Repair
Occasionally, the proximal neck may be very friable and
may not hold sutures, resulting in disruption of the
anastomosis. The answer, in the cold, clear light of day,
is to dissect back to healthy tissue. This is easier said
than done. If this is not possible and the situation is
really grim, there may be little option but to oversew
the aortic stump and perform an axillobifemoral bypass.
This is not the ideal, but it may be life-saving. Issues
of patency can be then argued another day.
Prevention
Dissect back to healthy aorta. Ensure that endarterec-
tomy of the proximal aorta, when necessary, is not too
extensive and that a decent amount of aorta is left to
sew to. It may also be useful to perform the proximal
anastomosis in an interrupted fashion with pledgelets
around the Prolene sutures to avoid cheese-wiring
through a particularly friable aortic neck.
Inspection of the Peritoneal Cavity and Closure
of the Flank Incision
See under Aortobifemoral Bypass by the Retroperitoneal
Approach, earlier.
POSTOPERATIVE COMPLICATIONS
Graft Infection/Aortoenteric Fistulas
Can occur days to years after the initial operation. The
most common site of aortoenteric stulas is the third part
of the duodenum. The cause of melena in a patient with
an aortic graft is often an aortoduodenal stula. These can
be difcult to diagnose. The bleeding point is frequently
not seen on routine endoscopy owing to its location in
59 AORTIC SURGERY 609
the third part of the duodenum. Classic changes can be
seen on CT. However, a high index of suspicion is
probably the best tool of all.
Consequence
Bleeding, often catastrophic, although the initial herald
bleed can be quite small.
Grade 4 complication
Repair
Options are (1) bilateral axilloprofunda artery bypass
with vein patch angioplasty of the common femoral
arteries and subsequent explantation of the graft, (2)
in situ replacement of the infected graft with femoral
veins (the Claggett procedure), and (3) in-line replace-
ment of an infected transabdominal graft, in which a
new graft is inserted retroperitoneally from the proxi-
mal aorta above the infection and tunneled to either
femoral artery. The infected graft is then removed via
a laparotomy.
Prevention
The retroperitoneal approach seems to confer some
immunity from this feared complication. An end-to-
end anastomosis also seems to reduce the likelihood of
this because the anastomosis lies more anatomically and
away from the duodenum.
Graft Limb Occlusion/Graft Occlusion
Consequence
Early postoperative occlusion usually results in acute
ischemia. Late occlusion can result in intermittent clau-
dication or rest pain.
Grade 3 complication
Repair
If this occurs early in the postoperative period, the
patient should return to the operating room for graft
thrombectomy and correction of the underlying tech-
nical defect. If this occurs as a late complication, the
most frequently employed option is femorofemoral
crossover grafting.
Prevention
Careful attention to surgical technique, especially
avoiding any kink or undue redundancy in the graft
limbs. Also, we feel it is mandatory to employ some
form of quality control. We use a handheld Doppler to
conrm good outow.
Pseudoaneurysm
This can occur months or years after the initial
operation.
Consequence
The primary concern is that this is a manifestation of
graft infection, and therefore, at the time of surgery, it
 610 SECTION X: VASCULAR SURGERY
is important to send samples of the graft and aneurysm
contents for culture. Small pseudoaneurysms (<2 cm)
in frail patients with limited life expectancy can be
observed. However, aneurysms in surgically t patients
merit intervention because they can often enlarge
impressively over relatively short intervals.
Grade 3 complication
Repair
Good preoperative imaging is important. The safest
way to manage pseudoaneurysms is to rst obtain
proximal control by a ank incision that starts at
McBurneys point and is continued laterally in line with
the 10th intercostal space. After division of the muscle
layers, the peritoneum is reected forward to give access
to the common and external iliac and the graft. A
separate, vertical right groin incision is made, and
control of the supercial femoral, profunda femoris,
and common femoral proximal to the graft is obtained.
After heparinization, the sac is opened. Often, all that
remains of the native common femoral is the posterior
wall with the orices of the supercial femoral and
profounda femoris arteries. The graft will have retracted
above the inguinal ligament. A new 8- or 10-mm graft
is brought into the operating eld and sewn end-to-end
onto the proximal graft in the pelvis and end-to-side
onto the common femoral remnant. Tackling such
aneurysms by means of a single vertical groin incision
is possible, but this invites problems if the aneurysm
sac is entered and proximal control cannot be estab-
lished. If infection is a reasonable concern for the
etiology of the pseudoaneurysm, routing of the recon-
struction extra-anatomically rst is recommended prior
to opening the pseudoaneurysm.
Prevention
Again, attention to surgical technique and use of non-
absorbable monolament sutures for the anastomosis
are key.
AVOIDING PITFALLS IN
UNUSUAL CASES
Inammatory AAA
Inammatory AAAs are difcult, regardless of surgical
approach. In patients with suitable anatomy, there is a case
for considering endovascular repair, regardless of the
patients tness for surgery. However, in patients who
need operative intervention, the retroperitoneal approach
may be better: The posterolateral aspect is typically spared
from the inammatory process compared with the anterior
aortic wall; the left renal vein is lifted interiorly and the
duodenum is moved away from the operative eld and
does not need to be dissected. This is supported by re-
ports in the literature, albeit involving small numbers of
patients.20,21 Our experience is that in patients with severe
retroperitoneal brosis, the retroperitoneal approach is
still a difcult operation and not quite the panacea por-
trayed in the literature.
Horseshoe Kidney
A horseshoe kidney (or fused renal ectopia) is one of the
places in which the retroperitoneal approach has clear
advantages over the transabdominal approach.22,23 With
horseshoe kidneys, the renal arteries are often multiple,
and it is essential to reimplant as many as possible either
individually or as a patch. With the kidney lifted forward
out of the operative eld, division of the isthmus is a moot
point. It also avoids injury to a ureter in an anomalous
position.
Retroaortic Left Renal Vein
The retroaortic left renal vein is present in 2% of patients,
and a circumaortic left renal vein is present in 3%.24 This
can make a left retroperitoneal approach difcult if not
noted prior to surgery. In order to avoid injury to the
renal vein in such circumstances, we drop the kidney:
place it back in its usual anatomic position rather than in
the exaggerated anterior position with the conventional
posterolateral retroperitoneal exposure. The kidney is
separated from the perinephric fat (this can be reasonably
vascular) and replaced on the posterior abdominal wall.
Reimplantation of Renal Arteries
If it is anticipated in advance that the renal arteries will
require reimplantation, we sew 6-mm Gore-Tex limbs
onto the aortic graft prior to starting the surgery. Follow-
ing adequate dissection of the aorta, the suprarenal aorta
and renal arteries are clamped. The aorta is transected, and
it is only at this stage that adequate access to the right
renal artery can be obtained. The proximal aortic anasto-
mosis is performed, and then the renal arteries are sewn
in place.
Approach to Suprarenal Aneurysms
Again the suprarenal aorta is dissected with division of the
left crus of the diaphragm. The aorta and renals are
clamped. The aorta is divided obliquely, and a graft is
sewn end-to-end.
Repair of Ruptured
AAA via the Left
Retroperitoneal
Approach
The key in the management of ruptured AAAs is rapid
proximal control of the aortic neck. For those unfamiliar
with the retroperitoneal approach, it may seem foolhardy
to perform a retroperitoneal approach in such circum-
stances. However, this has been our practice since 1989.
Our operative outcomes are reasonable.25

OPERATIVE STEPS
Step 1 Patient positioning
Step 2 Left ank skin incision/cross-clamp thoracic
aorta
Step 3 Dissection of aortic aneurysm
Step 4 Clamping distally and proximally suprarenal
clamp if needed
Step 5 Opening of aneurysm sac
Step 6 Proximal and distal anastomosis
Step 7 Inspection of peritoneal cavity and closure of
ank incision.
Patient Positioning
This is no different from that employed in elective aorto-
bifemoral or aneurysm repair cases. Familiarity with the
position on the part of the operating room team ensures
that the patient can be placed in the left lateral position
without delaying surgery.
Left Flank Skin Incision/Cross-clamp
Thoracic Aorta
We occasionally extend our incision far posterior so that
the incision can be deepened through the intercostal
muscles to access the lower thorax and allow for
cross-clamping of the lower thoracic aorta, which allows
time for more detailed dissection of the aortic neck. Once
the proximal neck is dissected, the clamp can then be
repositioned.
Dissection of AAA
With ruptured AAAs, most of the dissection has been
done by the rupture itself, as the most common site of
rupture is posterior and inferiorly. We always divide the
left crus of the diaphragm to facilitate rapid access to the
neck. We regard this as crucial in emergency situations.
One of the most common problems encountered in the
conventional transabdominal approach to ruptured aneu-
rysms is injury to the gonadal and left renal veins in an
already coagulopathic patient. The advantage of the ret-
roperitoneal approach is that the gonadal veins and the
left renal vein are pushed away from the operative eld.
In contrast to elective surgery, we clamp proximally rst.
As with elective cases, we minimize dissection around the
right common iliac artery and vein.
Opening of the Aneurysm Sac
This is performed in the same manner as elective surgery,
with oversewing backbleeding arteries. If the right
common iliac cannot be expeditiously controlled, we place
a size 14 Foley catheter down the artery to control back-
bleeding. A right suprainguinal incision can then be made
to access the right external iliac artery.
59 AORTIC SURGERY 611
Proximal and Distal Anastomoses
See Elective AAA Repair by the Retroperitoneal Approach
(Including Repair of Suprarenal and Juxtarenal AAAs),
earlier.
Inspection of the Peritoneal Cavity and Closure
of the Flank Incision
Special attention should be paid to inspection of the peri-
toneal cavity contents at the end of the operation to
ensure that there are no signs of colonic ischemia or
splenic injury.
SPECIAL PROBLEMS
Ischemic Colitis/Ischemic Bowel
Ischemic bowel is a relatively rare occurrence in elective
aortic surgery. However, in emergent repair, the incidence
of colon ischemia is 5% to 7%. It carries a mortality rate
of up to 80%. In order to reduce ischemic complications
after emergent AAA repair, we therefore have a policy of
colonoscopy within 48 hours of surgery. Our experience
shows 42% of patients develop colon ischemia after rup-
tured AAA repair. Of these patients, almost a quarter had
full-thickness necrosis of the bowel wall (grade 3 colonic
ischemia). Even with recognition of the problem and
prompt resection, the mortality rate in this subgroup of
patients was 55%.26
Grade 4/5 complication
CONCLUSIONS
Aortic surgery is difcult. It has the highest mortality rate
of any elective vascular surgical procedure. Mortality rates
in the United States for AAA repair are 5.6%,27 above what
is regarded acceptable for coronary artery bypass. They
have not altered appreciably since the 1980s, despite
advances in critical care and anesthesia. Evidence from
most centers suggests that mortality rates for aortoiliac
occlusive disease are even higher. These reect the com-
plexity of the surgery and the general health of our
patients. In this chapter, we have related problems we
have encountered in performing aortic surgery in the hope
that many of these experiences can be avoided by others
in the future.
REFERENCES
1. Pearce WH, Parker MA, Feinglass J, et al. The importance
of surgeon volume and training in outcomes for vascular
surgical procedures. J Vasc Surg 1999;29:768776;
discussion 777778.
 612 SECTION X: VASCULAR SURGERY
2. Chang BB, Shah DM, Paty PS, et al. Can the retroperito-
neal approach be used for ruptured abdominal aortic
aneurysms? J Vasc Surg 1990;11:326330.
3. Pierce GE, Turrentine M, Stringeld S, et al. Evaluation
of end-to-side v end-to-end proximal anastomosis in
aortobifemoral bypass. Arch Surg 1982;117:15801588.
4. Melliere D, Labastie J, Becquemin JP, et al. Proximal
anastomosis in aortobifemoral bypass: end-to-end or end-
to-side? J Cardiovasc Surg (Torino) 1990;31:7780.
5. Ameli FM, Stein M, Aro L, et al. End-to-end versus end-
to-side proximal anastomosis in aortobifemoral bypass
surgery: does it matter? Can J Surg 1991;34:243246.
6. Friedman SG, Lazzaro RS, Spier LN, et al. A prospective
randomized comparison of Dacron and polytetrauoroeth-
ylene aortic bifurcation grafts. Surgery 1995;117:710.
7. Prager M, Polterauer P, Bohmig HJ, et al. Collagen
versus gelatin-coated Dacron versus stretch polytetrauo-
roethylene in abdominal aortic bifurcation graft surgery:
results of a seven-year prospective, randomized multi-
center trial. Surgery 2001;130:408414.
8. Webster SE, Smith J, Thompson MM, et al. Does the
sequence of clamp application during open abdominal
aortic aneurysm surgery inuence distal embolisation? Eur
J Vasc Endovasc Surg 2004;27:6164.
9. Lipsitz EC, Veith FJ, Ohki T, Quintos RT. Should initial
clamping for abdominal aortic aneurysm repair be
proximal or distal to minimize embolization? Eur J Vasc
Endovasc Surg 1999;17:413418.
10. Shah DM, Darling RC III, Chang BB, et al. Access to the
right renal artery from the left retroperitoneal approach.
Cardiovasc Surg 1996;4:763765.
11. Cambria RP, Brewster DC, Abbott WM, et al. Transperi-
toneal versus retroperitoneal approach for aortic recon-
struction: a randomized prospective study. J Vasc Surg
1990;11:314324; discussion 324325.
12. Sicard GA, Reilly JM, Rubin BG, et al. Transabdominal
versus retroperitoneal incision for abdominal aortic
surgery: report of a prospective randomized trial. J Vasc
Surg 1995;21:174181; discussion 181183.
13. Kirby LB, Rosenthal D, Atkins CP, et al. Comparison
between the transabdominal and retroperitoneal
approaches for aortic reconstruction in patients at high
risk. J Vasc Surg 1999;30:400405.
14. Sieunarine K, Lawrence-Brown MM, Goodman MA.
Comparison of transperitoneal and retroperitoneal
approaches for infrarenal aortic surgery: early and late
results. Cardiovasc Surg 1997;5:7176.
15. Williams GM, Ricotta J, Zinner M, Burdick J. The
extended retroperitoneal approach for treatment of
extensive atherosclerosis of the aorta and renal vessels.
Surgery 1980;88:846855.
16. Shumacker HB Jr. Midline extraperitoneal exposure of the
abdominal aorta and iliac arteries. Surg Gynecol Obstet
1972;135:791792.
17. Shucksmith HS. Duodenal, sigmoid, and ureteric stulas
resulting from aorto-iliac grafts or endarterectomy. Br J
Surg 1968;55:402403.
18. Beach PM, Risley TS. Aorticosigmoid stulization
following aortic resection. Arch Surg 1966;92:805807.
19. Beall AC Jr, Crosthwait RW, De Bakey ME. Injuries of
the colon including those incident to surgery upon the
aorta. Surg Clin North Am 1965;45:12731282.
20. Todd GJ, DeRose JJ Jr. Retroperitoneal approach for
repair of inammatory aortic aneurysms. Ann Vasc Surg
1995;9:525534.
21. Fiorani P, Faraglia V, Speziale F, et al. Extraperitoneal
approach for repair of inammatory abdominal aortic
aneurysm. J Vasc Surg 1991;13:692697.
22. Canova G, Masini R, Santoro E, et al. Surgical treatment
of abdominal aortic aneurysm in association with horse-
shoe kidney. Three case reports and a review of technique.
Tex Heart Inst J 1998;25:206210.
23. Stroosma OB, Kootstra G, Schurink GW. Management of
aortic aneurysm in the presence of a horseshoe kidney. Br
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Advances in the surgical repair of ruptured abdominal
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Outcome of aggressive surveillance colonoscopy in
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progress? J Vasc Surg 2000;32:10911100.
60
Infrainguinal Revascularization
Christopher J. Abularrage, MD
and Richard F. Neville, MD
INTRODUCTION
Lower extremity revascularization is being offered to an
increasing number of patients. This is due in part to the
aging of our population, but the population is also increas-
ingly active and aware of the effects of peripheral arterial
disease on lifestyle and mobility. Advances in open and
endovascular therapies have allowed an increasingly aggres-
sive approach to revascularization for a patient population
that is becoming increasingly older and often sicker. These
factors continue to increase the number of prospective
patients seeking revascularization to increase mobility and
avoid amputation. Although the advent of sophisticated
endovascular techniques continues to push the limits of
catheter-based revascularization, open bypass will con-
tinue to play a major role in the revascularization of
the critically ischemic lower extremity. This may prove
especially true for those patients who are in need of
pulsatile ow directly to a specic angiosome to prevent
tissue loss.
The classic indications for revascularization are inca-
pacitating claudication, rest pain, and tissue loss including
gangrene and nonhealing ulcerations.1 Patient selection is
important in determining the optimal mode of therapy
because pain relief and maintenance of function are the
goals of revascularization and not the cure of atheroscle-
rosis. Claudication is rarely a limb-threatening situation,
and a failed intervention can result in a more complicated
revascularization and conversion to the threat of limb loss.
Whereas 25% of claudicants have progressive symptoms,
fewer than 20% require revascularization for limb salvage
after 10 years.2 The majority of infrapopliteal revascular-
ization procedures should be performed for patients in a
limb-threatening situation with symptoms manifesting as
pain at rest or tissue loss. In these patients, both an aggres-
sive approach to revascularization and proper wound care
are essential to maintain limb length and the ambulatory
status of the patient. This affects both life and limb.
The history and physical examination remain an impor-
tant tool in management of the vascular patient. The
history provides information about the indication for vas-
cular intervention as well as concurrent risk factors in
other arterial beds. The physical examination (pulses, skin
envelope) provides an assessment of the extent of vascular
involvement. The hand-held Doppler is widely used in
the evaluation of ischemia. An experienced examiner can
differentiate an acoustically normal from an abnormal
Doppler signal. The presence of a Doppler signal indicates
that there is blood ow in the examined artery; however,
it does not indicate whether this ow is adequate. The
severity of ischemic disease should be documented by
noninvasive vascular laboratory testing prior to any inter-
vention. These studies conrm the degree of ischemia and
serve as a baseline for future postprocedure follow-up.
The noninvasive vascular laboratory uses Doppler ultra-
sound to measure the ankle/brachial index (ABI), seg-
mental pressures, and waveform analysis and to generate
duplex images. Other important tests include pulse volume
recordings (PVR), transcutaneous oxygen tension (tcPO2)
and photoplethysmography (PPG). The ABI is measured
as the ankle pressure divided by the brachial pressure, with
a normal value of 1.0. In intermittent claudication, an ABI
of 0.5 to 0.9 is usually obtained, whereas in severe isch-
emia, the ABI is usually less than 0.5. Noncompressible
arteries lead to falsely high ankle pressures in more than
30% of diabetic patients3; therefore, other noninvasive
studies should be added to determine the adequacy of
blood ow in diabetics with ischemia.4 Segmental pres-
sures and waveforms can help localize vascular occlusive
disease. The tcPO2 measures the partial pressure of oxygen
that diffuses through heated skin.5 A tcPO2 can be accurate
in predicting healing. Healing is likely if tcPO2 is above
35 to 40 mm Hg, and unlikely if it is below 20 to
26 mm Hg. A tcPO2 regional index can be used to account
for changes in systemic arterial oxygen tension.6 To obtain
the regional index, the tcPO2 of the leg is divided by the
tcPO2 measured at a reference point (chest). Wounds with
a tcPO2 index below 0.4 are unlikely to heal, and those
with tcPO2 above 0.6 are likely to heal.7
After it has been determined that revascularization
is indicated, an imaging study is needed to plan the
appropriate procedure. Arteriography remains the most
common method for arterial imaging in order to plan
revascularization. However, new modalities such as duplex
ultrasound, magnetic resonance angiography, and com-
puted tomographic (CT) angiography are being used
 614 SECTION X: VASCULAR SURGERY

with increasing frequency. These new modalities avoid

the complications of arterial puncture and possible renal
dysfunction associated with arteriography. However, these
newer, noninvasive imaging modalities are still being
rened and require the involvement of physicians dedi-
cated to obtaining precise images. The chosen method
must allow the surgeon to identify the inow and outow
arteries as well as the adequacy of the runoffall key
factors for a successful bypass.
A successful bypass depends on careful preoperative
planning and meticulous attention to detail during the
operation. Preoperative decisions include choice of inow
artery, recipient artery, and the conduit for bypass. Error
in judgment in any of these decisions is a technical error
leading to graft failure. Meticulous dissection, conduit
preparation, and suturing of the anastomosis are crucial in
preventing intraoperative technical errors leading to early Figure 601 Transverse versus groin incision.
graft failure. There is little margin for error in suturing
anastomoses, especially to those small diseased arteries minimal tissue manipulation and respect for anatomic
below the knee. tissue planes can avoid the complications associated with
this portion of the procedure. There is some support for
the use of a transverse groin incision as opposed to a
KEY DECISION POINTS vertical incision in order to avoid lymphoceles and seromas
(Fig. 601). This decision should not compromise appro-
Bypass anatomy: inow artery, recipient artery priate arterial exposure.
Conduit: vein, prosthetic, composite

Improper Choice of Inow Artery

INDICATIONS Consequence
Graft failure.
Severe disabling claudication Grade 3 complication
Rest pain
Tissue loss or gangrene Repair
Improvement of inowproximal arterial angioplasty,
additional revascularization of the inow artery by a
OPERATIVE STEPS jump graft or extension of the existing bypass to an
appropriate inow source.
Step 1 Proximal artery exposure
Step 2 Distal artery exposure Prevention
Step 3 Preparation of conduit Preoperatively, adequate evaluation of the inow artery
Step 4 Tunneling of conduit through multiplanar arteriography is critical. Pre- and
Step 5 Intraoperative anticoagulation postlesion pressure measurements can be made at the
Step 6 Proximal anastomosis time of the arteriogram to delineate the hemodynamic
Step 7 Distal anastomosis signicance of an inow stenosis. If any doubt remains
Step 8 Evaluation of bypass at the time of surgery, an arterial pressure can be
Step 9 Wound closure measured with an intraoperative arterial line at the site
of the proximal anastomosis for comparison with the
patients proximal pressure (brachial, radial). The
OPERATIVE PROCEDURE
pressure gradient should not be more than 15 to
20 mm Hg.
Proximal Artery Exposure
Femoral Nerve Injury (Fig. 602)
Proximal arterial exposure involves proper choice of the
inow artery for bypass. Several methods exist to aid this Consequence
choice. Presence of a strong, palpable pulse and preop- Weakness in the extensor muscles of the thigh and
erative imaging should be considered. Any doubt requires paresthesias of the anterior thigh. Chronic pain can be
measurement of an arterial pressure, which can be per- observed in up to 15% of patients.9
formed at the time of surgery.8 Careful dissection with Grade 1 complication
 60 INFRAINGUINAL REVASCULARIZATION
Repair
Direct repair by peripheral nerve specialist.
Prevention
Nerve injuries occur approximately 4% of the time10
and can be prevented with meticulous surgical tech-
nique and an understanding of the injurys medial posi-
tion to the femoral artery. The femoral sheath should
be opened longitudinally to expose the femoral artery.
Figure 602 Proximal arterial exposure shows the proximity of
the femoral nerve to the inow artery.
A B
Figure 603 A, Incision planning for below-knee popliteal expo-
sure. B, Incision for below-knee popliteal exposure. C, Distal expo-
sure for the dorsalis pedis artery. D, Distal exposure for the plantaris
pedis branch of the posterior tibial artery.
615
Care must be taken to avoid transverse dissection
because femoral nerve injury may occur at the lateral
aspect of the dissection.
Distal Artery Exposure
Similar principles apply to the distal dissection as to the
proximal exposure. Ideally, distal arteries can be dissected
between muscle planes and not through a large mass of
muscle. If large amounts of muscle are being transected,
reconsider the proper plane of dissection (Fig. 603).
Venous Injury (Fig. 604)
Consequence
Injury to the corresponding veins that run in the vas-
cular pedicle with the outow artery can lead to intra-
operative blood loss and a decreased eld of vision and
limited exposure of the site for distal anastomosis.
Grade 3 complication
Repair
A careful repair of the venous injury with ne suture
must be performed with extra care given to control of
bleeding during the repair. Often, the repair must be
performed without formal vascular control through the
D
 616 SECTION X: VASCULAR SURGERY
Figure 604 Distal arterial exposure shows the proximity of the
tibial veins to the outow artery.
use of digital pressure and judicious use of ne-tipped
suction. Care should also be taken to avoid occlusion
of the vein owing to the repair. This can create local
venous hypertension and make the remaining venous
circulation more difcult to handle.
Prevention
Careful dissection of the outow artery from its cor-
responding veins, with exposure limited to that minimal
portion of the artery necessary for vascular control and
the construction of the anastomosis. Consideration can
also be given to the use of a proximal external pressure
cuff for vascular control. This allows a more minimal
dissection of the outow artery, thereby minimizing
the chance of venous injury and clamp injury to the
artery.
Common Peroneal Nerve Injury
Consequence
Footdrop secondary to loss of the dorsiexor and ever-
sion muscles of the foot as well as paresthesias on the
lateral aspect of the leg and the dorsum of the foot.
Grade 1 complication
Repair
Direct repair by a peripheral nerve specialist.
Prevention
The common peroneal nerve branches off the sciatic
nerve at the superior aspect of the popliteal fossa and
heads laterally with the medial border of the biceps
femoris muscle. It then passes over the posterior aspect
of the bular head. Care must be taken to avoid injury
to this nerve when exposing the below-knee popliteal
artery.
Deep Peroneal Nerve Injury
Consequence
Footdrop.
Grade 1 complication
Repair
Direct repair by a peripheral nerve specialist.
Prevention
The common peroneal nerve branches into the deep
and supercial peroneal nerves. The deep peroneal
nerve is most commonly injured during exposure of the
anterior tibial artery.
Supercial Peroneal Nerve Injury
Consequence
Paresthesias of the lateral aspect of the leg and the
dorsum of the foot.
Grade 1 complication
Repair
Direct repair by a peripheral nerve specialist.
Prevention
The supercial peroneal nerve courses along the lateral
aspect of the leg and can be injured during division of
the bula when accessing the below-knee popliteal
artery or the trifurcation. This can be prevented by
dividing the bular periosteum from distal to proximal
in order to identify the supercial peroneal nerve, which
courses around the upper bula. Avoidance of the
nerve can be further ensured by staying within the
subperiosteal plane.
Tibial Nerve Injury
Consequence
Weakness in plantar exion of the foot as well as par-
esthesias on the sole of the foot.
Grade 1 complication
Repair
Direct repair by a peripheral nerve specialist.
Prevention
The tibial nerve is a branch of the sciatic nerve that
passes through the popliteal fossa supercial to the
popliteal artery. It then travels on the posterior aspect
of the posterior tibial artery inferiorly to the foot. It is
most commonly injured during exposure of the popli-
teal and posterior tibial arteries.
Preparation of Conduit
Preparation of the conduit is obviously most important if
autogenous vein is available to use for the bypass. Sources
for venous conduit include the greater saphenous, lesser
saphenous, and arm veins. If vein is not available, pros-
thetic materials can be used prior to the choice of primary
amputation. However, every effort should be made to use
an autogenous reconstruction. In this case, the avoidance
of venous spasm and injury demands meticulous dissec-
tion and gentle vein handling. This is a crucial part of the
 60 INFRAINGUINAL REVASCULARIZATION
A Vein Spasm, Vein Injury, Poor Vein Quality
(Fig. 607)
B sufcient length. Otherwise, a prosthetic graft can be
Figure 605 A, Autogenous vein harvest for bypass conduit.
B, Vein harvest shows the vein cannula in place to administer
gentle hydrostatic dilation during harvest and a skin bridge for
enhancement of wound closure at the knee.
Figure 606 Saphenous vein harvest shows dissection of the
saphenous nerve in proximity to the vein.
Residual Arteriovenous Fistula (Fig. 608)
operation and not one that should be left to the most
junior member of the operating team (Fig. 605).
Saphenous Nerve Injury (Fig. 606)
Consequence
Paresthesias of the skin on the medial aspect of the
lower leg below the knee joint.
Grade 1 complication
Prevention
Saphenous nerve injuries can be prevented with an
understanding of its anatomy and relation to the saphe-
617
nous vein. The saphenous nerve is a cutaneous branch
of the femoral nerve. It travels with the supercial
femoral artery through the adductor canal and then
exits distal to the hiatus between the sartorius and the
gracilis muscles to join the course of the greater saphe-
nous vein. It may also be injured during medial expo-
sure of the above-knee popliteal artery.
Consequence
Graft thrombosis.
Grade 3 complication
Repair
Veins of adequate quality and diameter can be
sutured together to create a composite graft with
considered.
Prevention
Preoperative vein mapping with duplex ultrasound can
provide detailed information regarding the quality of
a potential vein graft. It can detect constriction of
veins secondary to sclerosis, previous manipulation,
or thrombophlebitis. It can also assess length and diam-
eter of the vein. These can be particularly important
when performing a tibial bypass for which a long
segment is necessary. Diameters greater than 3 mm for
reverse11 and 2 mm for in situ12 saphenous vein grafts
have been recommended to obtain adequate long-term
patency; however, judgment is required because the
vein may be suitable with intraoperative preparation.
Intraoperative preparation involves distal vein exposure
with the instillation of premixed vein solution prior to
more proximal dissection. This solution should be
instilled under enough pressure to gently dilate the
vein, but not to overdistend the vein, leading to endo-
thelial injury. Endothelial ischemic time should also be
minimized by allowing the vein to remain in place as
long as possible whether it is used in a reversed, trans-
located, or in situ conguration.
Consequence
Failure to locate and ligate all side branches from a
translocated in situ vein graft. Arteriovenous stula
causing low ow through the bypass with possible
thrombosis.
Grade 1/2/3 complication
Repair
Patent side branches can be located with manual palpa-
tion, Doppler ultrasound, or angiography. Once iden-
tied, these can be ligated with sutures or surgical clips.
If identied postoperatively, a small incision can be
made over the side branch with subsequent ligation.
 618 SECTION X: VASCULAR SURGERY

Prevention
Three types of stulas exist: small cutaneous branches
usually found in the thigh that do not greatly affect
graft ow; perforator branches that increase graft inow
but have no effect on distal graft ow; and perforator
branches that increase graft inow and decrease graft
outow.13 Prevention is aimed at carefully examining
the bypass intraoperatively and ligating all branches.
1
Failure to Lyse All Venous Valves (Fig. 609)
2
Consequence
Low ow through the bypass with possible
thrombosis.
Grade 1/2/3 complication
Repair
Intraoperative identication of untreated valves can be
made with Doppler ultrasound or angiography. Proper

4
RT GSV MID Thigh

2
1

Figure 608 Intraoperative completion angiogram shows a

patent arteriovenous stula (arrows) after in situ bypass. This
emphasizes the need for some type of completion study after
RT GSV PROX Thigh 4 bypass to ensure the desired result.

Figure 607 Duplex ultrasound image of the greater saphenous vein

taken preoperatively to assess vein quality and suitability for use as a bypass
conduit. A, Transverse view. B, Longitudinal view. This technique can also
guide the operative exposure and help avoid larger tissue aps that result
B in postoperative wound complications.
 60 INFRAINGUINAL REVASCULARIZATION 619

Figure 609 A, Intraoperative angiogram with valves properly lysed after

vein bypass. B, Intraoperative angiogram with the rst valve beyond the saphe-
nofemoral junction not properly lysed and impeding ow through the bypass
A
graft.

valve lysis must then be performed with the valvulo-
tome favored by the operating surgeon.
Prevention
The vein conduit can be used in one of three congu-
rations: reversed, in situ, or translocated. Reversed vein
grafts avoid the need for valvulotomy but may lead to
size mismatch when performing the anastomoses. The
in situ technique is advantageous because there is no
size mismatch between artery and vein, but valve lysis
is required with the vein often only partially exposed.
If care is not taken, the valvulotome can injure the vein,
most commonly at the site of a venous side branch. In
a recent prospective, randomized study, there were no
differences in the number of retained valves between
types of valvulotomes.14 Hemodynamically signicant
stenoses due to unlysed valves required revision 2.5%
of the time.15 The translocated technique also matches
size of the artery and vein and optimizes valve lysis
under direct observation, but it does increase venous
endothelial ischemic time compared with that of the in
situ technique. Translocated vein also allows possible
variation in the path of the bypass through the lower
extremity in order to avoid infection or heavy scar
formation. The operating surgeon should choose the
method with the most comfort and familiarity because
patency rates seem to be similar.16
Wound Infection or Dehiscence
Consequence
Wound infections of the vein harvest site can usually
be managed nonoperatively.
Grade 1 complication
Repair
Treatment typically includes antibiotic therapy with or
without local wound incision and drainage.
Prevention
Prevention is aimed at risk factor modication because
patients with diabetes mellitus and obesity are at
increased risk for vein harvest site infections.17 A recent
prospective, randomized trial found that endoscopic
vein harvest reduced leg wound complications from
7.4% to 19.4% compared with those of open vein
harvest.18 The endoscopic harvest time is signicantly
longer than that of the traditional harvesting tech-
nique, and care must be taken not to cause venous
spasm or injury during endoscopic vein harvest.19
Proper wound closure is also critical in preventing post-
 620 SECTION X: VASCULAR SURGERY

C
B
Figure 6010 A, Subcutaneous tissue should be closed to minimize dead space with monolament suture without tension. If required,
retention-type sutures can be placed through the skin in mattress fashion to take tension off the wound edges. B, Final wound closure.
C, Wound closure across a groin skin crease. Care must be taken to approximate the skin edges appropriately to avoid tension and wound
complications. The wound is appropriately closed.

operative wound complications. Important principles

to consider include closure without tension on the
wound edges, use of absorbable suture to minimize soft
tissue reactivity and inammation, and approximation
of the wound edges (Fig. 6010).
A
Tunneling of Conduit
Bypass grafts should be tunneled in away from areas of
infection and in such a way as to protect the graft from
wounds of future exposure. Vein grafts are often tunneled
in a subcutaneous position to allow for ease of follow-up
and revision in the future. Prosthetic grafts should be
tunneled in an anatomic location under muscular tissue
planes. Various tunneling devices are available and should
be chosen in order to allow atraumatic graft manipulation
with a minimum of tissue displacement (Fig. 6011).

Graft Kinking
Consequence
B
Low ow through the bypass with possible thrombosis.
Grade 1/2/3 complication Figure 6011 Graft tunneled without kinking or redundancy.
 60 INFRAINGUINAL REVASCULARIZATION 621

Repair
Kinking of a graft must be directly xed by reorienting
the graft throughout its course.
Prevention
Kinking of a bypass is rare, occurring 1% of the time.20
Reversed or translocated vein grafts should be marked
at their ends to maintain proper orientation and avoid
kinking throughout their course. Most polytetrauoro-
ethylene (PTFE) grafts have orientation markers to
prevent twisting or kinking of the graft during tunnel-
ing. If there is any question as to kinking, the graft
should be withdrawn and tunneled again.

Injury to Deep Structures

Consequence
Hemorrhage if a vessel is injured; neuropathy if a nerve
is injured.
Grade 1/3 complication
Repair
Bleeding vessels must be located and ligated or electro- A
cauterized. Bleeding from the graft tunnel can be dif-
cult to isolate but should not be left untreated.
Prevention
After exposure of the proximal and distal arteries, the
tunneler must be kept in specic tissue planes to avoid
injury to underlying neurovascular structures.9

Graft Stricture by Fascia or Tendon (Fig. 6012)

Consequence
If a deep anatomic tissue plane is chosen (especially for
above-knee femoral-popliteal bypass with prosthetic),
care must be taken not to cross different anatomic
compartments and to stay in the anatomic plane of the
native artery. Entrance and exit points from the tunnel
should be free of any tension. If a lateral course for the
graft must be used, the proximal portion of a bypass
may be constricted by the tense bands of the tensor
fascia lata, resulting in low ow and possible graft
thrombosis.
Grade 1/2/3 complication
Repair
Constriction of the bypass must be directly repaired by
creating a larger window through the fascia lata for the
bypass to travel.
Prevention
The fascia lata should be incised in cruciate fashion or
partially excised prior to placing the graft through it.
Intraoperative Anticoagulation
Intraoperative anticoagulation is used primarily to prevent
arterial thrombosis while the native arterial circulation
B
Figure 6012 A, Intraoperative angiogram or bypass graft com-
pression by the tendon during wound closure. B, Intraoperative
view of the tendon compressing the distal end of the bypass
graft.
is clamped and ow occluded to perform the arterial
anastomoses. Although most surgeons use systemic anti-
coagulation, regional administration can be performed
directly into the distal arterial tree.
Inadequate Anticoagulation
Consequence
Arterial thrombosis if anticoagulation is inadequate.
Grafts should always be allowed to evidence some
prograde bleeding prior to completion of the distal
anastomosis in order to ensure that no thrombus has
developed in the graft or clamped proximal artery.
Excessive bleeding, especially from suture needle holes
or raw tissue surfaces, can occur if anticoagulation is
overly aggressive.
Grade 1 complication
 622 SECTION X: VASCULAR SURGERY
Repair
Acute arterial thrombosis can usually be treated with
catheter thrombectomy because the thrombus is acute
and easily removed. An underlying lesion should be
considered as a cause for the thrombosis. If hemostasis
is necessary at the end of the procedure, it may be
necessary to reverse the effects of heparin by adminis-
tration of protamine. Protamine sulfate may be given
at a dose of 1 mg/100 units of circu-lating heparin if
there is excessive bleeding due to over-anticoagulation.
Prevention
Heparinization of the patient should be performed 1
to 2 minutes prior to clamping the vessels to prevent
thrombosis. This is done after exposure of the proximal
and target vessels and preparation of the conduit in
order to minimize blood loss and maintain a hemostatic
operating eld. It also avoids hemorrhage during tun-
neling of a graft. Heparin has a half-life of 1 to 1.5
hours and lasts approximately 3 to 4 hours. Adequate
anticoagulation can be followed with activated clotting
time (ACT). For peripheral vascular operations, an
ACT in the 250- to 350-second range is adequate.21
Proximal Anastomosis
Intimal Dissection
Consequence
Distal arterial thrombosis and ischemia.
Grade 1/2/3 complication
Repair
Intimal dissections can be repaired by placing full-
thickness tacking sutures through the arterial wall.
Prevention
In almost all circumstances, anastomotic sutures should
be placed from outside-to-inside through the conduit
and from inside-to-outside through the arterial wall.
This avoids dissection and lifting of the plaque from
the arterial media. Performance of a local endarterec-
tomy at the anastomotic site can be considered, but this
must be performed with care to minimize the risk of
intimal dissection and should prompt careful intraop-
erative evaluation of the anastomosis22 (Fig. 6013).
Intra-arterial Plaque Embolization
Consequence
Distal arterial thrombosis and ischemia.
Grade 2/3 complication
Repair
Catheter embolectomy.
Prevention
When gaining control of an artery, vascular clamps
should be placed on a noncalcied portion to avoid
plaque rupture and embolization. If the artery is calci-
ed, an attempt should be made to palpate the artery
and place the clamp so as not to fracture the plaque.
Anastomotic Dehiscence
Consequence
Anastomotic dehiscence can lead to a pseudoaneurysm,
hematoma, or hemorrhage, depending on the severity
of the dehiscence.
Grade 1/2/3 complication
Repair
Repair can be accomplished with complete revision of
the anastomosis using monolament sutures with or
without patch angioplasty.
Prevention
Anastomotic dehiscence was more common with the
use of Dacron grafts and absorbable sutures. With the
advent of PTFE grafts and synthetic nonabsorbable
monolament sutures, the rate of anastomotic pseu-
doaneurysm has greatly decreased. Currently, the great-
est risk factors are infection of the anastomosis, undue
tension, and inadequately placed sutures secondary to
technical failure.23,24 Duplex ultrasound may be useful
for evaluating the integrity of the anastomosis if the
diagnosis is in question.
Distal Anastomosis
Anastomotic Narrowing
Consequence
Narrowing of the distal anastomosis may lead to dis-
advantageous anastomotic hemodynamics and graft
thrombosis.
Grade 3 complication
Repair
If the anastomosis is narrowed, the suture line must be
transected and the narrowed portion redone or opened
with a patch angioplasty repair.
Prevention
Sutures placed at the toe and heel of the anastomosis
are the most important because these are the crucial
areas of the anastomosis to ensure good ow and
patency. The two best methods of suture placement at
the toe involve the parachute technique and sequen-
tial interrupted sutures at the toe with continuity after
the side sutures are placed. Both of these techniques
allow suture placement under direct vision at the criti-
cal areas of the anastomosis (Fig. 6014). Careful prox-
imal and distal control of the recipient artery is also
important to have a good length of artery to suture
under direct vision (Fig. 6015).
 60 INFRAINGUINAL REVASCULARIZATION 623

A B

C
Figure 6013 A, Anastomosis with the parachute technique of suture material allowing for precise placement of the sutures at the
critical portions of the anastomosis: toe and heel. B, Anastomosis with eversion of the graft material and arterial wall. C, Anastomosis
with the graft brought down with the parachute technique. D, Completed anastomosis with the toe carefully constructed.

Figure 6015 Arterial control prior to the construction of the

distal anastomosis.

Figure 6014 Distal anastomosis of a vein graft with the toe

carefully constructed.
 624 SECTION X: VASCULAR SURGERY

Lumen
PTFE grafts have decreased patency compared with
autogenous vein bypasses owing to an increased hyper-
Endothelial Platelets plastic response between the prosthetic material and
cells
the native artery.27 In the absence of available vein,
Migration * PTFE augmented with a distal vein patch provides a
Proliferation
Subendothelial larger orice at the arterial interface, thus increasing the
intima
Monocyte MIC diameter necessary for intimal hyperplasia to stenose the
Internal Macrophages
elastic io
n distal anastomosis.28,29 When combined with oral anti-
ig
rat
lamina M coagulation using warfarin sodium, this results in 4-year
Media
SMC primary patency and limb salvage rates of 63% and 79%,
respectively.30
A
Intraoperative Evaluation of Bypass
Poor Graft Performance
Consequence
After completion of a bypass, the outcome should be
evaluated prior to skin closure. Multiple techniques are
available including intraoperative Duplex ultrasound or
arteriography. Signs of an adequate result include a
palpable pulse in the target artery and a strong Doppler
signal that decreases with graft occlusion, but intraop-
erative imaging should be used liberally, if not rou-
tinely, to avoid graft thrombosis.
Grade 1/2/3 complication
Repair
Intraoperative arteriography allows the surgeon to
B
evaluate both anastomoses, the conduit, and the
Figure 6016 A, Schematic of the biology of myointimal hyper- outow arterial tree. If thrombosis has occurred,
plasia based on vascular smooth muscle cell migration and pro- thrombectomy should precede angiography. Any tech-
liferation. B, Hyperplastic lesion in a vein graft. The lesion was nical errors noted at either anastomosis or in the conduit
discovered at the site of a venous valve during routine graft surveil- must be repaired at the time of surgery. If no technical
lance using Duplex ultrasound.
errors are noted, arterial inow pressures should be
measured and conrmed. Hemodynamically signicant
inow gradients requiring inow augmentation may
Intimal Hyperplasia (Fig. 6016)
occur after the bypass owing to decreased outow
Consequence resistance31 (Fig. 6017).
Intimal hyperplasia can lead to midterm graft failure Angioscopy may also be used to evaluate a bypass after
between 30 days and 2 years postoperatively. completion. In a recent study of 90 grafts with normal
Grade 3 complication completion angiograms, 7 were found to have signicant
pathology on angioscopy.32 The authors concluded angios-
Repair copy was superior to angiography for disclosing conduit
Intimal hyperplasia can be repaired with patch angio- defects, although it did not provide adequate information
plasty of the lesion, a jump bypass around the lesion, about the distal arterial runoff. However, our experience
or angioplasty with a cutting balloon or atherectomy. with angioscopy was suboptimal owing to technical dif-
culties and clearing the endoluminal eld of blood for
Prevention adequate views.
Signicant hemodynamic lesions secondary to intimal Intraoperative duplex ultrasound has gained increasing
hyperplasia occur at a rate of 5% per year in vein grafts favor as the primary method to evaluate a bypass. The
with a majority in the rst 2 years and cannot be entire graft can be easily insonated as well as the anasto-
directly prevented.25 The goal of surveillance protocols moses and proximate arterial tree. Peak systolic velocities
is to identify correctable lesions before thrombosis, higher than 180 cm/sec, spectral broadening, and veloc-
thus permitting elective revision. Graft failure may be ity ratio greater than 3 (suggesting turbulent ow), and
indicated by (1) the recurrence of symptoms, (2) low peak systolic velocities higher than 30 to 40 cm/sec
velocities, or low-ow state, on duplex ultrasound, and high outow resistance with absent diastolic ow
(3) elevated velocities in an area of stenosis, or (4) a (suggesting low ow) predict a failing graft that warrants
decrease in the ABI.26 surgical intervention.33
 60 INFRAINGUINAL REVASCULARIZATION
A ultrasound.
B
Figure 6017 A, Completion angiogram after femoralto
plantaris pedis branch of the posterior tibial artery bypass using
the saphenous vein. B, Completion angiogram after a distal vein
patch bypass using polytetrauoroethylene (PTFE) to the anterior
tibial artery.
625
Prevention
Poor ow after completion of a bypass can be pre-
vented only with optimal patient selection and meticu-
lous surgical technique. Patients should have adequate
runoff because poor runoff scores are an independent
predictor of limb loss after revascularization.34
Wound Closure
Lymphatic Leak/Seroma
Consequence
Dissection of tissues may lead to lymphatic disruption
and leak. This occurs in approximately 0.5% to 4% of
patients with groin incisions.35,36 This can be diagnosed
by clear uid drainage and/or a lymphocele on duplex
Grade 1/2/3 complication
Repair
Conservative treatment with leg elevation and com-
pression stocking therapy may be sufcient, although
surgical excision and oversewing of the lymphatic
pedicle decreases hospital stay, lowers complication
rates, and results in fewer recurrences.37
Prevention
It is important to prevent lymphatic leaks because they
are a risk factor for subsequent infection.38 They can be
prevented by electrocauterization or ligation of divided
lymphatics at the time of surgery as well as by close
approximation of tissue planes.
Wound Hemorrhage
Consequence
Hematoma formation.
Grade 1/2/3 complication
Repair
If the cause of hemorrhage is believed to be surgical in
nature, wound exploration with ligation of bleeding
vessels is warranted (Fig. 6018). If the cause is medical,
cessation of antiplatelet or anticoagulant therapy
with possible reversal of anticoagulation with blood
products may be necessary. After the anticoagulation
has been reversed, hematoma evacuation may be
performed.
Prevention
Signicant hemorrhage occurring within 48 hours is
infrequent, occurring less than 2% of the time.39 The
most common causes are failure to ligate a venous or
arterial branch and suture line hemorrhage owing to
technical failure. Bleeding may also occur secondary to
arterial or venous damage during wound closure with
a needle. Many patients are placed on antiplatelet or
anticoagulant therapy to prevent graft thrombosis as
well as coronary complications. One study found that
treating patients at highest risk of major hemorrhage
 626 SECTION X: VASCULAR SURGERY
with aspirin instead of oral anticoagulants would result
in a reduction of nonfatal hemorrhages, but the reduc-
tion was outweighed by an increase in ischemic events
and graft occlusions.40
Wound Infection
Consequence
The incidence of wound infections ranges from 5%
to 20%.4143 Two classications of wound infections
exist (Table 601). The Johnson classication is more
thorough because it recognizes a group of wounds that
are not infected but have the possiblity of becoming
so. Class 1 and 2 wounds minimally alter a patients
hospital course, whereas class 4 wound infections
could lead to loss of the bypass graft and, possibly,
amputation.
Grade 1/2/3 complication
Repair
Treatment depends on the type of wound. Class 1
wounds may be observed. Class 2 wounds may need
local dbridement of the necrotic suture line. Prophy-
Figure 6018 Bleeding of blood through the interstices of a
PTFE graft. Direct suture repair or topical hemostatic agents such
as thrombin-soaked Gelfoam can be used to prevent surgical bleed-
ing from resulting in postoperative hematoma.
Table 601 Classication of Wound Complications
Szilagyi Classication74
Erythema and seroma without infection
Ischemic necrosis of the incision without infection
Ischemic necrosis and wound breakdown with infection Grade I (dermis only)
Grade II (subcutaneous)
Open, infected wound with involvement of bypass graft Grade III
lactic antibiotic therapy may be used for class 1 and 2
wounds in order to prevent conversion to class 3 or 4
and possible involvement of the bypass. Class 3 wounds
require more extensive dbridement of devitalized
tissue. Class 4 wounds represent a treatment dilemma.
Infection of the anastomotic segment typically requires
excision of the graft secondary to the higher incidence
of anastomotic dehiscence. If the infection of the graft
does not involve the anastomosis and there is no evi-
dence of systemic sepsis, graft thrombosis, or septic
emboli, graft-preserving therapy can be undertaken
with aggressive local wound dbridement and admin-
istration of broad-spectrum antibiotics, with or without
muscle ap coverage44 (Fig. 6019).
Infected prosthetic grafts are more difcult to treat with
antibiotic therapy alone because there is a high incidence
of recurrent sepsis.45 A large proportion of infected pros-
thetic grafts managed with incomplete graft removal
require subsequent operations. Complete excision of
infected graft material results in a signicant reduction in
sepsis, amputation, and early mortality.46
Prevention
Wound closure is of paramount importance after an
infrainguinal bypass. Closure of the proximal groin
wound begins by closing the femoral sheath. The sub-
cutaneous tissue is then closed in layers, ensuring ade-
quate coverage of the bypass. A layered closure decreases
the risk of postoperative complications. A similar layered
closure of the distal (and saphenectomy) incision is
performed. Care must be taken to avoid compression
of the graft during closure of the wounds (Fig. 6020).
The deeper layer closure should be performed with
monolament absorbable suture to reduce the inam-
matory response in the wound. Skin closure can be
completed with permanent suture or staples or a sub-
cuticular absorbable suture. The skin should not be
closed with a running permanent suture line because
this can lead to ischemia of the wound edges.
Risk factors for wound infection include poorly con-
trolled diabetes,47 end-stage renal disease,48 obesity,49 and
intraoperative hypothermia.50 Wound infections can be
Johnson Classication45 Treatment
Class 1 Observation
Antibiotics
Class 2 Observation
Dbridement
Antibiotics
Class 3 Dbridement
Antibiotics
Class 4 Dbridement
Antibiotics
Graft excision
Muscle ap
 60 INFRAINGUINAL REVASCULARIZATION
A agulability, or poor distal runoff.55 All are avoidable by
B rent atherosclerosis and occur beyond 2 years.
Figure 6019 A, Exposed graft after aggressive dbridement for
infection. The anastomosis is not involved. B, Sartorius muscle ap
coverage of the exposed graft.
Figure 6020 Wound closure. Primary closure over the graft
(arrow) with relaxing incision and xenograft closure.
627
prevented with the use of preoperative antibiotics,51 skin
cleansing with povidine-iodine or chlorhexadine,52 and
meticulous surgical technique. Finally, continuous wound
incisions for saphenectomy have a higher risk of infection
(27%42%) than incisions interrupted with skin bridges
(9%20%).53,54
Other Complications
Graft Thrombosis
Graft failure can be divided into early, midterm, and late
thrombosis. Early graft thrombosis occurs within 30 days
approximately 10% of the time43 and is typically caused
by technical failure, postoperative hypotension, hyperco-
careful preoperative planning, meticulous intraoperative
execution, and close postoperative monitoring. Hyperco-
agulable states occur in approximately 13% of patients
undergoing infrainguinal bypass and should be suspected
in any graft thrombosis that is recurrent or for which no
other cause can be identied.56
In two prospective studies, treatment of patients
with acute ischemia (014 days) with thrombolysis had
improved amputation-free survival and shorter hospital
stays. However, for patients with chronic ischemia (>14
days), surgical revascularization was more effective and
safer than thrombolysis.57,58
Midterm graft failures occur between 30 days and
2 years and are discussed under Distal Anastomosis,
earlier. Late graft failures are most likely related to recur-
Grade 2/3 complication
Myocardial Infarction
Clinical risk assessment is a key aspect of the preoperative
work-up for infrainguinal revascularization. Mild to mod-
erate coronary artery disease (CAD) is present in 92%
of patients with peripheral occlusive disease, and severe
CAD in present in 25%.59 In fact, perioperative myo-
cardial infarction occurs in 2% to 6.5% of patients after
infrainguinal revascularization.60 Two frequently used
CAD scoring systems are the Eagle criteria61 and the
American College of Cardiology/American Heart
Association (ACC/AHA) guidelines.62 Clinical assessment
by combined Eagle criteria and ACC/AHA guidelines
accurately estimates patients at higher risk for myocardial
infarction and cardiac-related mortality after vascular
surgery.63,64
Multiple studies have been performed examining the
utility of preoperative cardiac risk testing. In the past,
reversible perfusion defects found on stress tests were an
indication for coronary angiography. More recent studies
have shown that coronary revascularization in patients
with stable symptoms undergoing peripheral vascular pro-
cedures does not improve outcomes.65 Furthermore, pre-
operative stress tests do not predict survival in diabetic
patients.66 Based on these studies, coronary angiography
 628 SECTION X: VASCULAR SURGERY
and possible coronary revascularization should be reserved
for those patients with unstable angina. For the remain-
der of patients, risk factor modication including -
blockade,67,68 antiplatelet agents,69 and statin therapy70
remains the mainstay of cardiac optimization prior to
infrainguinal bypass.
Grade 15 complication
Pneumonia/Respiratory Failure
The high incidence of tobacco use and chronic obstruc-
tive pulmonary disease (COPD) in patients undergoing
lower extremity revascularization places them at increased
risk for pulmonary complications, including pneumonia
and respiratory failure. In a recent study, advanced age,
American Society of Anesthesiologists class 2 or higher,
functional dependence, COPD, and congestive heart
failure placed patients at risk for pulmonary compli-cations
after infrainguinal bypass.71 There was insufcient evidence
to support preoperative spirometry as a tool to stratify risk.
Preoperative smoking cessation, exercise regimen, bron-
chodilators, and inhaled steroids may all reduce the inci-
dence of postoperative pulmonary complications.
Grade 1/4/5 complication
Renal Failure
Acute renal failure occurs in approximately 1% to 2% of
patients undergoing lower extremity revascularization.72
This is most commonly caused by contrast nephropathy
and prerenal acute tubular necrosis. The incidence of
acute renal failure has decreased owing to advances in
critical care.
Grade 1/4/5 complication
Deep Venous Thrombosis
Lower extremity edema is a common occurrence after
infrainguinal bypass. Although typically asymptomatic in
nature, untreated edema can lead to an increased inci-
dence of wound infection. Edema is most likely caused by
venous or lymphatic disruption during dissection.73 It can
also be due to impaired venous return after years of chronic
ischemia. In each of these cases, treatment entails leg
elevation and possibly compression stocking therapy.
Deep venous thrombosis is a less common cause of post-
operative edema, but it must be ruled out to avoid pul-
monary embolism.
In a patient with a history of multiple graft thromboses
and deep venous thrombosis, a hypercoagulable state
must be considered.
Grade 1/2/5 complication
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25. Bandyk DF, Kaebnick HW, Stewart GW, Towne JB.
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26. Bandyk DF, Schmitt DD, Seabrook GR, et al. Monitoring
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J Vasc Surg 1989;9:286296.
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32. Woele KD, Kugelmann U, Bruijnen H, et al. Intraopera-
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34. Seeger JM, Pretus HA, Carlton LC, et al. Potential
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35. Tyndall SH, Shepard AD, Wilczewski JM, et al. Groin
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39. Taylor LM Jr, Edwards JM, Porter JM. Present status of
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44. Dosluoglu HH, Schimpf DK, Schultz R, Cherr GS.
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45. Johnson JA, Cogbill TH, Strutt PJ, Gundersen AL.
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1988;123:859862.
46. Mertens RA, OHara PJ, Hertzer NR, et al. Surgical
management of infrainguinal arterial prosthetic graft
infections: review of a thirty-ve-year experience. J Vasc
Surg 1995;21:782790.
47. Goodson WH 3rd, Hunt TK. Wound healing in experi-
mental diabetes mellitus: importance of early insulin
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48. OHare AM, Sidawy AN, Feinglass J, et al. Inuence of
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wound complications in continuous infrainguinal incisions
after lower limb arterial reconstruction: incidence, risk
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50. Kurz A, Sessler DI, Lenhardt R. Perioperative normother-
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51. Bandyk DF. Vascular graft infections: epidemiology,
microbiology, pathogenesis and prevention. In Bernhard
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54. Wengrovitz M, Atnip RG, Gifford RR, et al. Wound
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ment. J Vasc Surg 1990;11:156161.
55. Donaldson MC, Mannick JA, Whittemore AD. Causes of
primary graft failure after in situ saphenous vein bypass
grafting. J Vasc Surg 1992;15:113118.
56. Curi MA, Skelly CL, Baldwin ZK, et al. Long-term
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37:301306.
57. Results of a prospective randomized trial evaluating
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extremity. The STILE trial. Ann Surg 1994;220:251266.
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61
Arteriovenous Hemodialysis Access
Robyn A. Macsata, MD and Anton N. Sidawy, MD
INTRODUCTION
Currently, over 325,000 patients are on dialysis in the
United States, and more than 100,000 new patients begin
dialysis each year.1 Medicare spends over $18 billion
dollars annually in the care of these patients; a large
portion of the expenses is dedicated to dialysis access and
its complications.2 With these numbers, it is no surprise
that vascular access is a prevalent part of many surgeons
practices. With the ever-increasing numbers and cost of
care of these patients, it is imperative that surgeons provide
the most reliable dialysis access with the lowest possible
risk of complications.
Autogenous arteriovenous accesses have consistently
been shown to have excellent patency rates and low risk
of complications when compared with prosthetic arterio-
venous accesses. Two-year primary patency rates of autog-
enous access range between 34% to 69%, which is clearly
superior to the 2-year primary patency rates of prosthetic
access, which averages 25%.36 Complications of infection,
pseudoaneursyms, and seromas are rarely seen in autog-
enous access. With these benets, the disadvantages of
autogenous access, including a long maturation time,
failure to mature, and acute thrombosis, are acceptable.
In consideration of these data, the current Dialysis Out-
comes Quality Initiative (DOQI) recommendation is to
place autogenous access in at least 50% of all patients
requiring long-term access.7
In order to place long-term autogenous access with the
lowest risk of complications, preoperative evaluation is
essential. A thorough patient history is taken, document-
ing the patients dominant extremity, recent history of
peripheral intravenous lines, site of indwelling or previous
central lines, all previous access procedures, any history
of trauma or previous surgery to the extremity, and
all comorbid conditions. On physical examination, the
patients arm is evaluated for edema and varicosities. With
an upper arm tourniquet in place, the arm is inspected for
visible cephalic and basilic veins. Indications for preopera-
tive venography are listed in Box 611; venography may
be substituted with a venous duplex scan as long as the
surgeon recognizes the limitations of evaluating the central
venous system. To assess for adequate arterial inow, a
thorough pulse examination including Allens test is done.
Abnormal pulses in the planned operative extremity are
further evaluated with arteriogram.7,8
Box 612 lists the multiple access congurations pos-
sible in the upper and lower extremities as well as the body
wall.9 An autogenous access is always attempted before
prosthetic access, including use of basilic vein transposi-
tions. One-year primary patency rates of basilic vein trans-
positions range between 35% and 84% with an acceptably
low complication rate and are, therefore, an excellent
alternative to cephalic vein access.6,1013 Preference is given
to the nondominant arm over the dominant arm, followed
by distal location over proximal location. Controversy still
exists whether a prosthetic forearm access should be placed
before an upper arm autogenous access. The autogenous
access will likely offer longer patency but eliminates the
placement of subsequent forearm prosthetic access. There-
fore, this decision remains surgeon and patient dependent.
Lower extremity and body wall access are used only once
both upper extremity uses have been exhausted.7
INDICATIONS
Creatinine clearance less than 25 ml/min
Serum creatinine greater than 4 mg/dl
Patient within 1 year of anticipated need for dialysis
OPERATIVE STEPS
Autogenous Posterior Radial BranchCephalic
Direct Wrist Access (Fig. 611)
Step 1 Cephalic vein exposure and evaluation
Step 2 Posterior radial branch artery exposure
Step 3 Radial arterytocephalic vein anastomosis
Step 4 Ligation of venous branches
Step 5 Wound closure
Autogenous Brachial-Basilic Upper Arm
Transposition (Fig. 612)
Step 1 Basilic vein exposure and evaluation
Step 2 Basilic vein harvest with ligation of all side
branches (see Fig. 612A)
 632 SECTION X: VASCULAR SURGERY

Box 611 Indications for Venous Imaging before
Access Insertion
Edema in the extremity in which an access is planned
Collateral vein development in any planned access site
Differential extremity size of the considered limb
Current or previous transvenous catheter, of any type, in
the ipsilateral limb
Previous arm, neck, or chest trauma or surgery in venous
drainage of the planned access site
Multiple previous accesses in the ipsilateral extremity
Adapted from NKF-K/DOQI Clinical practice guidelines for vascular
access: update 2000. Am J Kidney Dis 2001;37(suppl):S137S181.
Box 612 Arteriovenous Access Conguration
Forearm
Autogenous
Autogenous posterior radial branchcephalic direct access
Autogenous radial-cephalic direct wrist access
Autogenous radial-cephalic forearm transposition
Autogenous brachial-cephalic forearm looped
transposition
Autogenous radial-basilic forearm transposition
Autogenous ulnar-basilic forearm transposition
Autogenous brachial-basilic forearm looped transposition
Autogenous radial-brachial indirect saphenous vein
translocation
Autogenous brachial-antecubital forearm looped
saphenous vein translocation
Prosthetic
Prosthetic radial-antecubital forearm straight access
Prosthetic brachial-antecubital forearm loop access

Upper Arm
Autogenous
Autogenous brachial-cephalic upper arm direct access
Autogenous brachial-cephalic upper arm transposition
Autogenous brachial-basilic upper arm transposition
Autogenous brachial-brachial (vein) upper arm
transposition
Autogenous brachial-axillary indirect saphenous vein
translocation
Prosthetic
Prosthetic brachial-axillary access

Lower Extremity
Autogenous
Autogenous femoralgreater saphenous looped access
transposition
Autogenous femoralsupercial femoral vein looped
access transposition
Prosthetic
Prosthetic femoral-femoral looped inguinal access
Figure 611 Autogenous posterior radial branch-cephalic direct
wrist access. (Adapted from Weiswasser JM, Sidawy AN. Strategies Body Wall
of arteriovenous dialysis access. In Rutherford RB (ed): Vascular Prosthetic
Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005; p 1671.) Prosthetic axillary-axillary chest access
Prosthetic axillary-axillary chest loop access
Prosthetic axillaryinternal jugular chest loop access
Step 3 Brachial artery exposure (see Fig. 612B) Prosthetic axillary-femoral body wall access
Step 4 Tunneling of basilic vein Prosthetic femoral-femoral suprainguinal access
Step 5 Brachial arterytobasilic vein anastomosis
Adapted from Sidawy AN, Gray R, Besarab A, et al. Recommended
(see Fig. 612C) standards for reports dealing with arteriovenous hemodialysis
Step 6 Wound closure accesses. J Vasc Surg 2002;35:603610.

OPERATIVE PROCEDURE
Prosthetic Brachial-Antecubital Forearm Loop
Access (Fig. 613)
Venous Exposure
Step 1 Antecubital vein exposure and evaluation
Early Autogenous Arteriovenous Access
Step 2 Brachial artery exposure
Thrombosis
Step 3 Tunneling of graft
Step 4 Arterial graft anastomosis Consequence
Step 5 Venous graft anastomosis Access thrombosis and inability to dialyze. The major
Step 6 Wound closure disadvantage of autogenous arteriovenous access is
 61 ARTERIOVENOUS HEMODIALYSIS ACCESS 633

Figure 613 Prosthetic brachial-antecubital forearm loop access.

B (Reproduced with permission from Weiswasser JM, Sidawy AN.
Strategies of arteriovenous dialysis access. In Rutherford RB (ed):
Vascular Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005;
p 1674.)

publication of the DOQI guidelines in 1997, surgeons

C ary to small caliber of the outow vein, the autogenous
Figure 612 Autogenous brachial-basilic upper arm transposi-
tion. A, Basilic vein harvest with ligation of all side branches.
B, Brachial artery exposure. C, Brachial arterytobasilic vein
anastomosis.
primary failure rates that range from 3% to 33%.1315
Early access thrombosis is due to technical failure and
most commonly is associated with inadequate venous
outow, which may be secondary to inadequate caliber
of the outow vein or central venous stenosis. With the
have become more aggressive in attempting to place
autogenous accesses, with use of smaller-caliber veins,
possibly increasing early thrombosis rates.16 This is
believed to be an acceptable risk for the potential ben-
ets of autogenous access.7 Other less common causes
include poor arterial inow and anastomotic stenosis.
Grade 3 complication
Repair
Thrombectomies and thrombolysis are rarely successful
for autogenous accesses. If early thrombosis is second-
arteriovenous access is redone using a different vein
(e.g., conversion of an autogenous radial-cephalic
direct wrist access to an autogenous radial-basilic
forearm transposition) or, if no vein is available, a pros-
thetic arteriovenous access. Central venous stenosis
(Fig. 614) is treated with angioplasty and/or stenting
or venous bypass (e.g., subclavian veintointernal
jugular vein bypass [Fig. 615]), followed by a new
autogenous or prosthetic arteriovenous access. An arte-
rial inow stenosis is treated with angioplasty and/or
 634 SECTION X: VASCULAR SURGERY

C
A

Figure 614 Central venous stenosis. A, Upper extremity vari-

cosities associated with central venous stenosis. B, Upper extremity
edema associated with central venous stenosis. C, Venogram of the
patient in Figure 614A demonstrates subclavian vein stenosis. (A
and C, Reproduced with permission from Adams ED, Sidawy AN.
Nonthrombotic complications of arteriovenous access for hemodi-
alysis. In Rutherford RB (ed): Vascular Surgery, 6th ed. Philadelphia:
B
Elsevier Saunders, 2005; p 1700.)

stenting or proximal arterial bypass to restore adequate
arterial inow followed by a new autogenous or pros-
thetic arteriovenous access. An alternative approach is
to move the stula either proximally or to another
extremity where arterial inow is adequate. Anasto-
motic stenosis is a primary technical failure and is
redone with close attention to surgical technique.
Prevention
Preoperative evaluation with a thorough history and
physical examination is imperative to place functional
autogenous arteriovenous accesses. We perform a pre-
operative venous duplex scan on all patients with the
indications listed in Box 611 and any patient whose
supercial veins cannot be visualized on physical exam-
ination. The cephalic or basilic veins are used for autog-
enous access only if they are a minimum of 2.0 mm in
diameter.17 Preoperative venography is completed in
any patient with high clinical suspicion for central
venous stenosis or with abnormal ndings on venous
duplex scan. Occurrence of central venous stenosis is
decreased by keeping use of central venous lines to a
minimum. If they are required, the internal jugular
approach is preferable. Central venous stenosis is treated
before placement of arteriovenous stula with angio-
plasty and/or stenting or proximal venous bypass. Any
patient with an abnormal pulse examination is further
evaluated with upper extremity pulse volume record-
ings and segmental pressures. Any drop in pressure
greater than 30 mm Hg is believed to be abnormal,
and if possible, we place the arteriovenous access in an
alternate extremity or proximal to the area of stenosis.
If an arteriovenous access must be placed in an area of
abnormal arterial inow, the patient is further evaluated
with arteriogram, and any stenosis is treated with
angioplasty and/or stenting or arterial bypass. To avoid
anastomotic stenosis, care must be taken intraopera-
tively to ensure patency of this small anastomosis.7,8
Late Arteriovenous Access Thrombosis
Consequence
Access thrombosis and inability to dialyze. Primary
patency rates of autogenous accesses range between
 61 ARTERIOVENOUS HEMODIALYSIS ACCESS
Int. juglar v.
A Axillary v.
B activator (t-PA). Both percutaneous mechanical throm-
Figure 615 Subclavian veintointernal jugular bypass. A, Sub-
clavian veintointernal jugular bypass using a 6-mm expanded
polytetrauoroethylene (ePTFE) prosthetic graft. B, Postoperative
venogram of subclavian veintointernal jugular bypass using a 6-
mm ePTFE prosthetic graft. (A, Reproduced with permission from
Adams ED, Sidawy AN. Nonthrombotic complications of arterio-
venous access for hemodialysis. In Rutherford RB (ed): Vascular
Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005; p 1701.)
43% and 84% at 1 year and 34% and 69% at 2 years and
are superior to primary patency rates of prosthetic
accesses of 41% to 54% at 1 year and 24% to 25% at 2
years.36,10,11,1315 Late arteriovenous access thrombosis
is most commonly due to intimal hyperplasia (Fig.
616A). In an autogenous access, this usually occurs
just distal to the anastomosis; however, it may occur
anywhere along the venous outow tract. In a pros-
thetic access, intimal hyperplasia occurs at the graft
venous anastomosis. Central venous stenosis is a second
common cause of late autogenous and prosthetic arte-
riovenous access failure.
Grade 2/3 complication
Repair
Thrombectomies and thrombolysis are rarely successful
in autogenous stulas. If late thrombosis is due to
intimal hyperplasia in the outow vein, the autogenous
arteriovenous access is redone using a different outow
635
vein (e.g., converting an autogenous radial-cephalic
direct wrist access to an autogenous radial-basilic
forearm transposition) or using a proximal site of access
(e.g., converting an autogenous radial-cephalic direct
wrist access to an autogenous brachial-cephalic upper
arm direct access). Central venous stenosis (see Fig.
614) is treated with angioplasty and/or stent place-
ment or proximal venous bypass (e.g., subclavianto
internal jugular bypass [see Fig. 615]), followed by
placement of a new arteriovenous access.
Thrombectomies and thrombolysis may be successful in
acutely thrombosed prosthetic accesses and are attempted
before abandoning the access for a new site. Because the
inciting lesion is most often located in the graftvenous
anastomosis, surgical thrombectomy is performed by
exposing this anastomosis and opening it longitudinally.
The thrombectomy is performed with a Fogarty catheter,
taking care to identify the arterial plug to ensure complete
clot removal (see Fig. 616B). A patch angioplasty of the
distal anastomosis is performed to alleviate the outow
stenosis and prevent recurrent thrombosis. Alternatively,
a jump graft using autogenous vein or prosthetic graft
may be performed around the distal anastomosis (see
Fig. 616C). Percutaneous mechanical thrombectomy has
recently been popularized as an alternative to open surgi-
cal thrombectomy. Another minimally invasive option is
thrombolysis with urokinase or tissue-type plasminogen
bectomy and thrombolysis must be followed by a contrast
study and repair of the inciting stenosis with angioplasty
and/or stent placement to prevent recurrent thrombosis
of the access.18
Prevention
Dialysis access surveillance and preemptive correction
of subclinical stenosis have been shown to prolong
access survival.19 Therefore, nephrologists monitor
dialysis access using multiple different techniques
including physical examination, dialysis venous pressure
measurements, access blood ow assessment, and urea
recirculation.19,20 Any abnormalities noted are further
assessed by duplex ultrasound. Any increase in peak
systolic velocity greater than 4 : 1 or any peak systolic
velocity less than 200 ml/min is believed to be abnor-
mal, and a stulogram is obtained.21 Any abnormalities
are treated with venous angioplasty and/or stenting or
open surgical techniques including patch angioplasty or
proximal venous bypass.22
Venous Hypertension
Consequence
Patients may be clinically asymptomatic with only
increased dialysis venous pressures or may present with
clinical symptoms including prolonged puncture site
bleeding, extremity edema, and varicosities. In severe
cases, bluish discoloration of the skin, ulceration of the
ngertips, and neuralgias may occur2325 (see Fig. 61
 636 SECTION X: VASCULAR SURGERY
C
Figure 616 Later arteriovenous access thrombosis due to intimal hyperplasia. A, Cross-section of intimal hyperplasia at the prosthetic
graftvenous anastomosis. B, Arterial plug seen with complete thrombus removal performed with a Fogarty catheter. C, Jump graft placed
around the prosthetic graftvenous anastomosis to prevent future thrombosis.
4A and B). Both groups of patients are at risk for access
thrombosis. Venous hypertension occurs irrespective of
whether an autogenous or a prosthetic access is placed
and is secondary to central venous stenosis (see Fig.
614C) with or without venous valvular incompetence.
Approximately 50%26 of patients on dialysis will develop
a central venous stenosis, but only 15% to 20% will be
clinically symptomatic.27
Grade 2/3/4 complication
Repair
Central venous stenosis is initially treated with angio-
plasty and/or stenting and, if unsuccessful, open surgi-
cal repair. Open surgical repair techniques include
internal jugulartosubclavian vein turndown with
direct anastomosis of the internal jugular vein to the
subclavian vein distal to the subclavian vein occlusion
or subclavian veintointernal jugular vein bypass2830
(see Fig. 615). Valvular incompetence is treated with
ligation of all veins distal to the outow anastomosis
noted to have reux. Patients in whom the central
venous stenosis is not amenable to endovascular or
open surgical techniques require access ligation. Unfor-
tunately, these patients will require a new access in a
different location.
B
Prevention
Preoperative evaluation with a thorough history and
physical examination is important to detect possible
central venous stenosis. We perform a preoperative
venous duplex scan on all patients with the indications
listed in Box 611. Preoperative venography is com-
pleted in any patient with a high clinical suspicion for
central venous stenosis or with abnormal ndings on
venous duplex scan. To prevent occurrence of central
venous stenosis, placement of central venous lines are
kept to a minimum, and if required, an internal jugul-
ar approach is preferred. All central venous stenoses
are treated before placement of arteriovenous access
with angioplasty and/or stenting or proximal venous
bypass. To decrease the incidence of venous reux
intraoperatively, the distal vein being used for the stula
is ligated and an end veintoside artery anastomosis is
performed.
Failure to Mature
Consequence
Inability to access graft for dialysis. Failure to mature
is the second major disadvantage of autogenous access.
Rates vary widely in the literature, ranging from 3% to
 61 ARTERIOVENOUS HEMODIALYSIS ACCESS
Figure 617 Ligation of large side branches after completion of
an autogenous radial-cephalic direct wrist access to improve access
maturation.
38%; however, average maturation times are consistent
at 3 months.46,1012,15 This occurs secondary to either
inadequate venous dilation associated with venous side
branches or a deep location of the venous outow
tract.
Grade 3 complication
Repair
Any large side branches of the outow vein are ligated
(Fig. 617). If the vein is located too deep, which is
seen most commonly with radial cephalic direct wrist
access, an incision is made overlying the venous outow
tract, and the vein is transposed supercially and placed
directly underneath the skin.
Prevention
Patients are examined preoperatively, and the super-
cial veins with their major side branches are marked. If
the veins are not easily visualized, a venous duplex scan
is used to evaluate patency and size of both cephalic
and basilic veins as well as any side branches. The
cephalic vein, basilic vein, and all side branches are
marked. Intraoperatively, before the anastomosis, the
venous outow is distended with heparinized saline and
the vein is reassessed. All side branches not previously
visualized are marked. If a thrill cannot easily be felt
through the skin, the vein is believed to be too deep.
Before performing the arteriovenous anastomosis, the
vein is transposed supercially for adequate cannulation
in the future. After completing the anastomosis, all side
branches are ligated to allow for adequate distention of
the vein.
Arterial Dissection
Arterial Steal
Consequence
Symptoms vary from mild coolness and paresthesias,
which occur only on dialysis, to severe rest pain, paral-
ysis, and gangrene and may appear immediately or be
delayed after arteriovenous stula placement. Arterial
637
steal occurs secondarily to low access tract resistance,
creating a reversal of blood ow in the arterial outow
tract toward the access and away from the hand. Arte-
rial occlusive disease increases resistance in the distal
outow of the arteriovenous access, which also contrib-
utes to the pathophysiology.31 Arterial steal occurs in
both prosthetic and autogenous access and is seen in
approximately 10% of all accesses placed. However,
only in 1% of distal forearm accesses and 3% to 6% of
upper arm accesses are clinical symptoms severe enough
to warrant surgical intervention.3237
Grade 3/4 complication
Repair
Mild cases with minimal clinical symptoms usually
resolve spontaneously after several weeks. Cases that do
not resolve and those with severe symptoms require
surgical treatment; multiple surgical techniques have
been reported. Ligation of the access will instantly
resolve the symptoms but leaves the patient without a
dialysis access. Banding of the access tract (Fig. 618A)
creates a stenosis that increases the resistance to the
blood ow in the access and reverses arterial ow in the
distal artery. However, it is difcult to judge the degree
of stenosis required to alleviate the steal without causing
thrombosis of the access. Ligation of the distal outow
artery has been reported as a successful technique in
patients with distal access and a patent palmer arch;
however, this approach does not restore possible
required inow to the hand. Distal revascularization
with interval ligation (DRIL) (see Fig. 618B) entails
ligation of the arterial outow tract just distal to the
takeoff of the access followed by placement of a bypass
from the artery proximal to the takeoff of the access to
the artery distal to the area of ligation. This procedure
eliminates reversal of ow in the distal outow artery
while keeping the access patent and perfusion pressures
to the hand constant. Complete relief of symptoms has
been reported in greater than 90% of patients. Primary
1-year patency rates range from 86% to 100% for the
arterial bypass and from 69% to 86% for the arteriove-
nous access.3840
Prevention
Preoperative pulse examination should reveal equal and
normal pulses bilaterally. Any patient with an abnormal
pulse examination is further evaluated with upper
extremity pulse volume recordings and segmental pres-
sures. Any drop in pressure greater than 30 mm Hg is
believed to be abnormal, and if possible, the arteriove-
nous access is placed in an alternate extremity or prox-
imal to the area of stenosis. If an arteriovenous access
must be placed in an area of abnormal arterial inow,
the patient is further evaluated with an arteriogram,
and any stenosis is treated with angioplasty and/or
stenting or arterial bypass. Intraoperatively, with autog-
enous access, care is taken to make the arteriovenous
 638 SECTION X: VASCULAR SURGERY

the anastomosis is not critical with prosthetic access;

the outow is limited by the size of the graft.

Ischemic Monomelic Neuropathy

Consequence
Acute pain, parasthesias, and weakness or paralysis of
the hand and forearm immediately after placement of
arteriovenous access. On physical examination, the
patients hand remains warm with palpable radial and
ulnar pulses. Ischemic monomelic neuropathy (IMN)
A occurs secondary to arterial steal, leading to ischemia
of the nerves, which produces neurologic decits of the
median, radial, and ulnar nerves but is not sufcient to
cause muscle or skin necrosis. IMN occurs only rarely
with both autogenous and prosthetic accesses originat-
ing at or proximal to the brachial artery.4143
Cephalic vein Grade 3/4 complication
Repair
Early treatment is imperative to prevent hand paralysis;
therefore, access surgeons should have a high index of
Brachial artery suspicion. Because IMN is a form of arterial steal, the
treatment options are similar.
See Treatment under Arterial Steal, earlier.
Prevention
IMN may be completely avoided by placement of access
using arterial inow distal to the brachial artery. Because
IMN is a form of arterial steal, preoperative evaluation
and prevention are similar.
Reverse saphenous
See Prevention under Arterial Steal, earlier.
vein graft

Anastomosis
Congestive Heart Failure
Consequence
Dyspnea and bilateral lower extremity edema. High-
output cardiac failure is a rare complication of both
B autogenous and prosthetic accesses, occurring in 2% to
4% of accesses placed.44,45 High-output congestive heart
Figure 618 Treatment options of arterial steal. A, Banding of
arteriovenous access. B, Distal revascularization with interval liga- failure occurs secondary to decreased total peripheral
tion (DRIL) entails ligation of the arterial outow tract just distal resistance, which is compensated for by an increase in
to the takeoff of the access followed by placement of a bypass from total cardiac output. Cardiac output may increase to
the artery proximal to the takeoff of the access to the artery distal over 8.0 L/min with access ow accounting for over
to the area of ligation. (A and B, Reproduced with permission from 50% of the cardiac output.46,47 To maintain such a high
Adams ED, Sidawy AN. Nonthrombotic complications of arterio- output, myocardial contractility and heart rate must
venous access for hemodialysis. In Rutherford RB (ed): Vascular relatively increase, which ultimately leads to cardiac
Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005; pp 1698 failure.48,49
1699.) Grade 3/4/5 complication
Repair
Ligation of the access will reverse the high-output
anastomosis as small as possible, 6 to 8 mm at the cardiac failure but leaves the patient without dialysis
largest. Also, interrupted sutures, which allow the anas- access. Banding of the arteriovenous access tract is an
tomosis to enlarge with time, are avoided. These tech- alternative approach; however, similar to arterial steal,
niques will prevent subsequent dilation of the outow it is hard to judge the amount of stenosis required to
tract creating increased ow in the access and an reduce the cardiac output without thrombosis of the
increased propensity toward arterial steal. The size of access.
 61 ARTERIOVENOUS HEMODIALYSIS ACCESS
Prevention
When placing autogenous access, the anastomosis is
kept between 6 and 8 mm in maximum diameter. Also,
interrupted sutures, which allow the anastomosis to
enlarge with time, are avoided. These techniques will
prevent subsequent dilation of the outow tract creat-
ing increased ow in the access, which ultimately leads
to high-output cardiac failure. With prosthetic accesses,
a graft with a maximum diameter of 6 mm is placed,
to avoid a similar low-resistance circuit.
Wound Closure
Infection
Consequence
Diffuse cellulitis or focal abscess (Fig. 619) overlying
the access. One of the biggest advantages of autoge-
nous access is average infection rates of 5%, which are
clearly superior to infection rates of 20% seen with
prosthetic accesses.50 Infectious organisms appear to be
independent of type of access. There is usually a pre-
dominance of gram-positive organisms, most com-
monly Staphylococcus aureus. However, up to 25% of
infections may involve gram-negative organisms or be
polymicrobial.51,52
Grade 1/3 complication
Repair
Autogenous access infection usually responds to 2 to 4
weeks of broad-spectrum antibiotics. Any associated
abscess is drained with preservation of the access. A trial
of broad-spectrum antibiotics is attempted in prosthetic
Figure 619 Abscess cavity surrounding the prosthetic graft.
639
accesses presenting with only a mild cellulitis. However,
most prosthetic infections require abscess drainage with
removal of the infected portion of the graft. If either
anastomosis is involved, the entire graft is removed to
prevent anastomotic disruption.
Prevention
With such a lower risk of infection associated with
autogenous arteriovenous access, autogenous access is
placed when at all possible. If a graft is required, close
attention to sterile surgical technique is mandatory.
Dialysis technologists must also practice sterile tech-
nique in the routine cannulation of all types of access.
Hemorrhage
Consequence
Intraoperative diffuse bleeding. Postoperative incisional
bleeding or hematoma formation. This occurs second-
ary to uremia-associated platelet dysfunction.
Grade 1/3 complication
Repair
Diffuse hemorrhage is treated with 1-deamino-8-D-
arginine vasopressin (DDAVP).53,54 Other options
include cryoprecipitate54 and activated factor VII.55
Patients with large hematomas are taken back to the
operating room for drainage.
Prevention
If possible, anticoagulants and antiplatelet agents are
stopped 1 week prior to access placement. Surgery is
performed 24 hours after dialysis to allow for adequate
recovery of platelet function. Recombinant human
erythropoietin (rHuEPO) is given on dialysis, which
increases hematocrit and improves platelet function.
Other options include preoperative transdermal
estrogen56 and vitamin K.57
Seroma
Consequence
Slowly increasing uid collection surrounding the arte-
riovenous access (Fig. 6110), which usually occurs
within 1 month of access placement. This complication
affects only prosthetic access and occurs in 0.5% to 4%
of these patients.58,59 The exact etiology is unknown,
but it is presumed to occur from transudation of serous
uid from porous grafts.60
Grade 2/3 complication
Repair
Multiple surgical treatments have been reported includ-
ing serial aspiration, incision and drainage, cyst removal,
and graft replacement. Graft replacement is shown to
be most successful, with a 92% cure rate.61 When replac-
ing the graft, a new graft made of different material is
placed through a new tunnel.
 640 SECTION X: VASCULAR SURGERY
Figure 6110 Seroma cavity overlying the prosthetic graft.
Figure 6111 Multiple asymptomatic pseudoaneurysms that
developed several years after placement of an autogenous radial-
cephalic direct wrist access. (Reproduced with permission from
Adams ED, Sidawy AN. Nonthrombotic complications of arterio-
venous access for hemodialysis. In Rutherford RB (ed): Vascular
Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005; p 1696.)
Prevention
With essentially no occurrence of seroma, autogenous
arteriovenous accesses are placed when at all possible.
Other Complications
Pseudoaneurysms
Consequence
Increased risk of hemorrhage, thrombosis, pain, and
cosmetic issues. Pseudoaneurysms (Fig. 6111) are
seen much more frequently in prosthetic accesses, with
an occurrence rate of 5% to 11% compared with an
average rate of 3% seen with autogenous accesses.36,6264
Pseudoaneurysms occur secondary to continuous punc-
turing of the access in the same site by dialysis unit
personnel.
Grade 1/2/3 complication
Repair
Most pseudoaneurysms may be safely monitored
without intervention; however, if the pseudoaneursym
size is signicantly increasing over time or the skin
overlying the pseudoaneurysm is very thin or ulcerated,
intervention is indicated. Traditional open surgical
treatment is to excise the involved portion of autoge-
nous or prosthetic access and replace it with either
transposed vein or prosthetic graft. In most cases, dial-
ysis is continued by accessing the uninvolved portion
of the access; however, temporary access is sometimes
required. An alternative approach recently being devel-
oped is endovascular treatment with covered stent
grafts. Current studies show initial success rates up to
100% and primary patency rates at 6 months that range
from 29% to 70%.6567
Prevention
With a clearly lower pseudoaneursym occurrence rate,
autogenous arteriovenous anastomoses are placed when
at all possible. Dialysis technologists are encouraged to
routinely rotate dialysis access puncture sites.
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43. Miles AM. Upper limb ischemia after vascular access
surgery: differential diagnosis and management. Semin
Dial 2000;132:312315.
44. Taylor SM, Eaves FL, Weatherford DA, et al. Results and
complications of arteriovenous access dialysis grafts in the
lower extremity: a ve year review. Am Surg 1996;62:
188191.
45. Murphy GJ, White SA, Knight AJ, et al. Long-term
results of arteriovenous stulas using transposed autolo-
gous basilic vein. Br J Surg 2000;87:819823.
 642 SECTION X: VASCULAR SURGERY
46. Bednarek-Skublewska A, Jozwiak L, et al. Acute cardiac
failure secondary to brachiocephalic arteriovenous stula
in patients on chronic haemodialysis. Pol Arch Med Wewn
2004;112:12211227.
47. Isoda S, Kajiwara H, Kondo J, Matsumoto A. Banding a
hemodialysis arteriovenous stula to decrease blood ow
and resolve high output cardiac failure: report of a case.
Surg Today 1994;24:734736.
48. Murray BM, Rajczak S, Herman A, Leary K. Effect of
surgical banding of a high-ow stula on access ow and
cardiac output: intraoperative and long-term measure-
ments. Am J Kidney Dis 2004;44:10901096.
49. Savage MT, Ferro CJ, Sassano A, Tomson CRV. The
impact of arteriovenous stula formation on central
hemodynamic pressures in chronic renal failure patients:
a prospective study. Am J Kidney Dis 2002;40:753
759.
50. Churchill K, Taylor KW, Cook RJ. Canadian hemodialysis
morbidity study. Am J Kidney Dis 1992;19:214234.
51. Marr KA, Sexton DJ, Conlon PJ. Catheter-related
bacteremia and outcome of attempted catheter salvage in
patients undergoing hemodialysis. Ann Intern Med 1997;
127:275280.
52. Saad TF. Bacteremia associated with tunneled, cuff
hemodialysis catheters. Am J Kidney Dis 1999;34:1114
1124.
53. Andrassy K, Ritz E. Uremia as a cause of bleeding. Am J
Nephrol 1985;5:313319.
54. Wolfson AB, Singer I. Hemodialysis-related emergencies:
II. J Emerg Med 1987;6:6170.
55. Ng HJ, Koh LP, Lee LH. Successful control of post-
surgical bleeding by recombinant factor VIIa in a renal
failure patient given low molecular weight heparin and
aspirin. Ann Hematol 2003;82:257258.
56. Sloand JA, Schiff MJ. Benecial effect of low-dose
transdermal estrogen on bleeding time and clinical
bleeding in uremia. Am J Kidney Dis 1995;26:2226.
57. Dember LM. Critical care issues in the patient with
chronic renal failure. Crit Care Clin 2002;18:421440.
58. Borrero E, Doscher W. Chronic perigraft seromas in
PTFE grafts. J Cardiovasc Surg 1988;29:4649.
59. Ahn SS, Machleder HI, Gupta R. Perigraft seroma:
clinical, histologic, and serologic correlates. Am J Surg
1987;154:173178.
60. Szilagyi DE. In discussion of Kaupp et al. Graft infection
or graft rejection? Arch Surg 1979;114:1422.
61. Blumenberg RM, Galfand ML, Dale WA. Perigraft
seromas complicating arterial grafts. Surgery 1985;97:194
203.
62. Rivers SP, Scher LA, Sheehan E, et al. Basilic vein
transposition: an underused autologous alternative to
prosthetic dialysis angioaccess. J Vasc Surg 2002;36:202.
63. Chia KH, Ong HS, Teoh MK, et al. Chronic haemodialy-
sis with PTFE arteriovenous grafts. Singapore Med J
1999;40:685690.
64. Lenz BJ, Veldenz HC, Dennis JW, et al. A three-year
follow-up on standard versus thin wall ePTFE grafts for
hemodialysis. J Vasc Surg 1998;28:464470.
65. Najibi S, Bush RL, Terramani TT, et al. Covered stent
exclusion of dialysis access pseudoaneurysms. J Surg Res
2002;106:1519.
66. Silas AM, Bettmann MA. Utility of covered stents for
revision of aging failing synthetic hemodialysis grafts: a
report of three cases. Cardiovasc Intervent Radiol
2003;26:550553.
67. Sapoval MR, Turmel-Rodrigues LA, Raynaud AC, et al.
Cragg covered stents in hemodialysis access: initial and
midterm results. J Vasc Interv Radiol 1996;7:335342.
62
Venous Surgical Pitfalls
Niten Singh, MD and James Laredo, MD
INTRODUCTION
Surgery on the supercial venous system is typically per-
formed to address two specic conditions of the lower
extremities: (1) symptomatic varicose veins and (2) super-
cial venous insufciency. Varicose veins of the lower
extremity are dilated supercial veins that are classied
according to their size: small telangiectatic veins (spider
veins); larger (13 mm) intradermal veins, which are not
usually tortuous, called reticular veins; and nally, true
varicose veins, which are greater than 3 mm and tortu-
ous.1,2 These veins can cause cosmetic problems as well as
pain. The overlying skin can darken as hemosiderin from
the static blood is deposited in the area.3 Also, with the
surrounding nerves, a sensation of dull aching is often
described by the patient. The vast majority of patients
with symptomatic varicose veins also have supercial
venous insufciency. Supercial venous insufciency is a
condition in which the valves present in the supercial
veins are incompetent, which results in reux of blood
within the vein. Reux of blood within the supercial
veinsnamely, the greater and lesser saphenous veins
results in elevated venous pressure. Venous hypertension
leads to lower extremity edema, pigmentation, stasis der-
matitis, lipodermatosclerosis, and venous ulceration of the
lower extremities.
The objective of surgical intervention in patients
with both symptomatic varicose veins and supercial
venous insufciency is twofold: removal of the symptom-
atic varicose veins and treatment of the supercial venous
insufciency.4
INDICATIONS
Symptomatic varicose veins
Supercial venous insufciency
OPERATIVE STEPS
Step 1 Stripping of GSV
Step 2 Ligation of GSV
Step 3 Laser or radiofrequency ablation of GSV
Step 4 Stab avulsion of varicose veins
OPERATIVE PROCEDURE
Stripping of the GSV
The procedure is performed with the patient under general
or regional anesthesia. A transverse incision in the groin
is performed one to two ngerbreadths from the pubic
tubercle. The saphenofemoral junction (SFJ) is identied
(Fig. 621), and all of the tributaries of the GSV are
ligated. The GSV is then divided at the SFJ and the stump
is suture-ligated. A stripping device (Fig. 622) is then
introduced into the GSV via a small incision in the lower
thigh. The device is passed proximal to the groin incision,
and the divided GSV at the SFJ is secured to the stripper
and removed via the thigh incision5 (Fig. 623). The vein
is usually removed above the knee only to avoid injury to
the saphenous nerve, which is within the proximity of the
GSV below the knee.
Injury to the Saphenous Nerve
Consequence
Owing to its proximity especially below the knee,
saphenous nerve injury may occur and result in chronic
neuropathic pain in the region of the saphenous
nerve.
Grade 1 complication
Repair
Conservative therapy with pain control and observation
may sufce if there is a traction-type injury. However,
persistent pain may require local injection and possible
neurolysis.6
Prevention
If the GSV is to be stripped, many advocate stripping
only the thigh portion of the GSV. Nerve injuries
are less likely if stripping is carried out only in this
segment.
Hematoma within the Saphenous Vein Tract
Consequence
As the GSV is stripped, its tributaries are avulsed in
the thigh, and bleeding from these may lead to
 644 SECTION X: VASCULAR SURGERY

Incision

Common
femoral, v.
Superficial
epigastric v.
Saphenofemoral Inguinal
junction ligament

Superficial
circumflex
iliac v.
Anterior femoral
cutaneous v. Sup.
external
pudendal v.

Greater saphenous n. Accessory

saphenous v.
Greater saphenous v.

Incision

Figure 621 Saphenofemoral junction (SFJ).

Common fermoral v.

Common femoral v.

Olive tip Olive tip

Greater saphenous v.

Greater saphenous v. Accessory saphenous v.

Figure 622 Vein stripper. Figure 623 Stripping of the greater saphenous vein (GSV).

ecchymosis, hematoma, and possible permanent skin
discoloration.
Grade 1 complication
Repair
Conservative measures are employed initially, using
compression and warm compresses. If the overlying
skin becomes threatened owing to a tense hematoma,
evacuation of the hematoma should be carried out.
Prevention
Leg elevation immediately after stripping and pressure
over the stripping site in the thigh are usually sufcient.
Other techniques that have been described are the use
of a tourniquet and internal packing of the stripping
site as well as tumescent anesthesia.1
Ligation of the GSV
The procedure is performed with the patient under general
or regional anesthesia. A transverse incision in the groin
is performed one to two ngerbreadths from the pubic
tubercle. The SFJ is identied, and all of the tributaries of
the GSV are ligated. The GSV is then divided at the SFJ
and suture-ligated.7
Misidentication of the SFJ
Consequence
If the SFJ is misidentied, the femoral vein may be
mistaken for the GSV and ligated, which would result
in massive limb swelling that could lead to limb
threat.
Grade 4 complication
Repair
Repair/reestablish continuity of the femoral vein with
likely anticoagulation.
Prevention
Visualization of the GSV at the SFJ and clear identica-
tion are the keys to prevention of this injury. If needed,
further dissection may be done around the femoral vein
to ensure that the junction is visualized.
Incomplete Ligation of the Tributaries of
the GSV
Consequence
Incomplete identication of the tributaries of the GSV
may lead to continued ow and reux through the GSV
and recurrence of varicosities in the leg.7
Grade 1 complication
Repair
Exploration and identication of the GSV and its
tributaries and likely stripping the vein.
62 VENOUS SURGICAL PITFALLS 645
Prevention
Dissecting the SFJ and ligating all tributaries of the
GSV can obviate recurrence.
GSV Ablation
The procedure is performed with the patient under
local anesthetic with sedation (oral or intravenous) and
requires vascular duplex ultrasound imaging. The patient
is positioned supine, the ipsilateral thigh is externally
rotated, and the knee is exed with a bump placed under
the distal thigh. This position allows complete duplex
imaging of the common femoral vessels and GSV. Next,
the ipsilateral common femoral vessels are imaged and
identied. The GSV is then imaged from the SFJ to the
knee.
Local anesthetic is used to anesthetize the skin overlying
the GSV at the knee/distal thigh. Under ultrasound guid-
ance, the GSV is punctured with a micropuncture needle,
followed by placement of a 0.014 guidewire through the
needle. A small 4-Fr catheter is placed into the GSV over
the 0.014 guidewire. The 0.014 guidewire is removed,
and a 0.035 J or Bentson guidewire is placed into the
GSV and advanced into the common femoral vein. The
laser catheter or radiofrequency catheter is advanced into
the GSV over the 0.035 guidewire and positioned at the
SFJ under ultrasound guidance (Fig. 624A). The guide-
wire is removed, and the laser or radiofrequency catheter
is pulled 2 cm distal to the SFJ (see Fig. 624B). The laser
ber or radiofrequency probe is then inserted into the
catheter. Tumescent anesthesia (200400 ml) is inltrated
into the perivenous tissues under ultrasound guidance.
The laser ber or radiofrequency probe is then armed, and
laser energy or radiofrequency energy is delivered to the
GSV during pullback of the laser ber or radiofrequency
probe. Energy delivered to the GSV results in ablation of
the vein.
Based on the less invasive nature and comparable results,
ablation of the GSV using laser or radiofrequency energy
is now becoming the preferred method of treating GSV
incompetence.8,9
Assessment of the common femoral vein and SFJ to
document preservation of ow is then performed prior to
wrapping the leg with an Ace bandage.
Injury to the Common Femoral Vein
Consequence
Because the procedure is performed with ultrasound
guidance, this complication is exceedingly rare. Guide-
wire or catheter injury to the common femoral vein
may result in bleeding and hematoma formation.
Grade 1 or 3 complication
Repair
Guidewire injury or catheter injury may require explo-
ration and repair of the injury.
 646 SECTION X: VASCULAR SURGERY

Laser

Stenotic
Common femoral v.
common
femoral v.

Greater
saphenous v.

Figure 624 Position of the laser catheter in the GSV.

A, Catheter tip at the SFJ. B, Catheter tip advanced 2 cm
A B distal to the SFJ.

Prevention
Ultrasound guidance will prevent guidewire or catheter
injuries.
Thermal Injury to the Common Femoral Vein
Consequence
Thermal injury to the common femoral vein can occur
if the laser ber or radiofrequency probe is present
within the common femoral vein at the time of energy
delivery.
Grade 1 or 3 complication
Repair
Thermal injury to the common femoral vein may
require operation and reconstruction of the vein.
Prevention
Careful ultrasound imaging and positioning of the laser
or radiofrequency catheter, prior to insertion of the
laser ber or radiofrequency probe, will prevent thermal
injury to the common femoral vein.
Skin Burns
Consequence
Burn injury is often at or near the insertion site of the
laser catheter or radiofrequency probe and is caused by
delivery of energy to a supercial portion of the GSV
or at the skin insertion site. Thermal injury can also
occur from energy traveling through supercial tribu-
taries of the GSV.
Grade 1 or 3 complication
Repair
Most burn injuries often require only local wound care.
However, for extensive burn injuries, local dbride-
ment and skin grafting may be required.
Prevention
Liberal use of perivenous tumescent anesthesia and
cessation of energy delivery before removing the laser
ber or radiofrequency probe from the GSV and skin
insertion site.
Deep Vein Thrombosis
Consequence
Thrombus may form within the proximal stump of the
ablated GSV and may propagate up into the common
femoral vein. This is more likely to occur with radio-
frequency ablation than with laser ablation.
Grade 1 complication
Repair
Anticoagulation with warfarin sodium (Coumadin) is
indicated when there is thrombus protruding into or
propagation of thrombus into the common femoral
vein. Vena cava lter placement may be indicated in
cases of free-oating thrombus within the common
femoral vein.
Prevention
The incidence of deep vein thrombosis (DVT) has
been reported to be 0.3% with laser ablation and
2.1% with radiofrequency ablation of the GSV. Post-
operative venous duplex scanning may be indicated in

high-risk patients (patients with a history of DVT or
thrombophilia).
Supercial Thrombophlebitis
Consequence
Supercial thrombophlebitis may develop in the ablated
GSV or in the supercial tributaries of the GSV.
Grade 1 complication
Repair
The majority of cases of supercial thrombophlebitis
will resolve with nonsteroidal anti-inammatory agents,
leg elevation, and warm compresses.
Prevention
Perioperative antibiotic administration and meticulous
aseptic surgical technique.
Stab Avulsion of Varicose Veins
The varicose veins are marked preoperatively, usually just
before bringing the patient to the operating room. Small
stab incisions overlying the marked varicose veins are
made, and the varicose veins are elevated into the incisions
and avulsed and/or ligated. The varicose veins are
removed, and the small incisions are closed with a buried
absorbable suture or Steri-Strips. Use of a thigh tourni-
quet may minimize blood loss.
Injury to the Saphenous Nerve
Consequence
Nerve injury may occur during stab avulsion of varicose
veins in close proximity to the saphenous vein and the
saphenous nerve below the knee. Injury may result in
chronic neuropathic pain in the region of the saphe-
nous nerve.
Grade 1 complication
Repair
Conservative therapy with pain control and observation
may sufce if there is a traction-type injury. However,
if this does not improve, local injection with long-
acting local anesthetic and possible neurolysis may be
required.9
Prevention
Stab avulsion of varicose veins in the area of the GSV
below the knee should be carefully performed.
Subfascial Endoscopic
Perforator Surgery
Perforating veins connect the supercial to the deep
venous system. Venous valves within these perforators
62 VENOUS SURGICAL PITFALLS 647
allow unidirectional ow from the supercial to the deep
venous system.10 The incompetence of these perforating
veins can lead to venous ulcerations of the skin overlying
the perforating vein. The Linton procedure for incompe-
tent perforating veins was a radical operation in which
perforating veins were directly ligated through a longitu-
dinal incision made over the medial leg, posterior to the
medial border of the tibia. This technique was compli-
cated by wound problems secondary to the overlying
unhealthy skin that would often fail to heal.11 More
recently, a less invasive techniquesubfascial endoscopic
perforator surgery (SEPS)has been developed to address
the incompetent perforating veins.
INDICATION
Venous ulcerations of skin overlying perforating vein
OPERATIVE STEPS
Step 1 Mark incompetent perforating vein on skin pre-
operatively under duplex guidance
Step 2 Exsanguinate affected limb using Esmarch
bandage and thigh tourniquet inated to
300 mm Hg to create bloodless eld
Step 3 Place 10-mm endoscope in medial aspect of calf
10 cm distal to tibial tuberosity and medical to
anterior edge of tibia
Step 4 Inate endoscopic balloon to dissect subfascial
space
Step 5 Remove balloon and insufate with 30 mm Hg
of CO2 to visualize space
Step 6 Place second 5-mm port distal to rst, near but
well above ankle, to perform clipping and divi-
sion of perforators
Step 7 Use standard laparoscopic surgery clips to clip
and divide all visualized perforaters
Step 8 Wound closure
Exsanguinate the Affected Limb Using
an Esmarch Bandage and a Thigh
Tourniquet Inated to 300 mm Hg to
Create a Bloodless Field
DVT
Consequence
Patients with an unknown hypercoagulable disorder or
prolonged placement of the tourniquet may develop a
DVT, which could lead to worsening of the chronic
venous insufciency symptoms and potential pulmo-
nary embolism (PE).
Grade 1 complication
Repair
Anticoagulation is the mainstay of therapy for DVT.
 648 SECTION X: VASCULAR SURGERY

Prevention Step 2 Perform cavagram to note diameter of IVC and

Avoidance of the tourniquet as well as administering
heparin prior to tourniquet placement may alleviate Step 3
this problem. Postoperatively, early ambulation and Step 4
compression stockings, if tolerated, may decrease the
incidence.
level of renal veins
Deploy lter below level of renal veins
Obtain hemostasis over insertion site with
manual compression for 5 to 10 minutes

Wound Closure
Wound Complications
Consequence
Many of these patients have nonhealing ulcers in the
lower extremity as a consequence of chronic venous
insufciency and have fragile skin, which can lead to
wound breakdown/infection, which can become a
chronic problem in this patient population.
Grade 1 complication

Repair
Local wound care and antibiotics are the mainstays of
treatment.

Prevention
Administration of perioperative antibiotics and meticu-
lous care in closure of these wounds.

Inferior Vena Cava

Filter Placement A
Placement of inferior vena cava (IVC) lters is indicated
when anticoagulation is contraindicated or has failed in
patients with DVT. In addition, placement of IVC lters
is indicated in patients with severe head injuries and with
spinal cord injuries that may make these high-risk trauma
patients prone to PE.12 As technology has evolved the
delivery system has become lower prole in size compared
with the initial percutaneous Greeneld lter, which
required a 28-Fr sheath. Currently, some devices require
a 6-Fr delivery system, which can reduce the length of
compression of the insertion site and local thrombosis of
the insertion site.13

INDICATIONS

Anticoagulation contraindicated or has failed in patients

with DVT
Severe head injuries and spinal cord injuries in patients
prone to PE

OPERATIVE STEPS B
Step 1 Obtain venous access via internal jugular or Figure 625 A, Filter placed over right renal vein. B, Migration
femoral approach of lter over bifurcation of iliac veins.

Venous Access
Hematoma, Arterial Puncture, Creation of
an Arteriovenous Fistula
Consequence
Often, in the obese or edematous patient, the venous
access site is not readily apparent and numerous
attempts may be employed to gain access, which could
lead to any of the common access complications.
Grade 1 complication
Repair
If the artery is entered and recognized, removal of the
needle and manual compression are all that are required.
Hematomas can usually be managed conservatively
unless overlying skin necrosis is noted. If an arteriove-
nous stula (AVF) is noted, conservative management
is usually the initial management. However, if the limb
is compromised, the AVF can be ligated.
Prevention
The use of anatomic landmarks is usually sufcient
in nonobese patients (i.e., using the pulsation of the
femoral artery and puncturing the medially located
femoral vein). With portable ultrasound machines more
readily available, image-guided access should be per-
formed whenever possible.
Filter Deployment
Filter Misplacement and Migration
Consequence
Not sizing the IVC properly (the majority of lters are
designed for an IVC < 30 mm) may lead to migration
of the lter, which could enter the right atrium; place-
ment over the renal veins may cause thrombosis of the
renal veins (Fig. 625).
Grade 2 complication
Repair
Endovascular snares and retrieval devices often obviate
the need for operative retrieval. However, if these fail,
direct surgical retrieval may be necessary.
Prevention
Performing a cavagram and proper sizing of the IVC
to ensure that the lter is properly sized and below the
level of the renal veins.
62 VENOUS SURGICAL PITFALLS 649
REFERENCES
1. Bergen JJ. Varicose veins: treatment by interventional
including sclerotherapy. In Rutherford RB (ed): Vascular
Surgery, 6th ed. Philadelphia: Elsevier Saunders, 2005; pp
22512267.
2. Allegra C, Antiganani P, Bergan JJ. The C of CEAP:
suggested denitions and renements. An International
Union of Phlebology conference of experts. J Vasc Surg
2003;37:129.
3. Georgiev M. Post sclerotherapy hyperpigmentations: a
one year followup. J Dermatol Surg Oncol 1989;15:214
219.
4. Goldman MP, Weiss MA, Beren JJ. Diagnosis and
treatment of varicose veins: a review. J Am Acad Dermatol
1994;31:393398.
5. Goren G, Yellin AE. Invaginated axial saphenectomy by a
semirigid stripper: perforate-invaginate stripping. J Vasc
Surg 1994;20:970977.
6. Morrison C, Dalsing MC. Signs and symptoms of
saphenous nerve injury after greater saphenous vein
stripping: prevalence, severity, and relevance for modern
practice. J Vasc Surg 2003;38:886890.
7. Rutherford RB, Sawyer JD, Jones DN. The fate of
residual saphenous vein after partial removal or ligation.
J Vasc Surg 1990;12:422428.
8. Manfrini S, Gasbarro V, Danielsson G. Endovenous
management of saphenous vein reux. J Vasc Surg 2000;
32:330342.
9. Proebstle TM, Gl D, Lehr HA, et al. Infrequent early
recanalization of greater saphenous vein after endovenous
laser treatment. J Vasc Surg 2003;38:511516.
10. Mozes G, Gloviczki P, Menawat SS, et al. Surgical
anatomy for endoscopic subfascial division of perforating
veins. J Vasc Surg 1996;24:800808.
11. Kalra M, Gloviczki P. Management of perforator vein
incompetence. In Rutherford RB (ed): Vascular Surgery,
6th ed. Philadelphia: Elsevier Saunders, 2005; pp 2268
2286.
12. Rodriguez JL, Lopez JM, Proctor MC. Early placement of
prophylactic vena caval lters in injured patients at high
risk for pulmonary embolism. J Trauma 1996;40:797
802.
13. Ascher E, Hingorani A, Yorkovich WR. Complications of
vena cava lters. In Towne JB, Hollier LH (eds): Compli-
cations in Vascular Surgery, 2nd ed. New York: Marcel
Dekker, 2004; pp 569579.
63
Endovascular Interventions
Niten Singh, MD and David Deaton, MD
INTRODUCTION
Endovascular therapy has changed the spectrum of vascu-
lar care that a surgeon can offer a patient. In the past,
procedures such as angioplasty were believed to be
reserved for short-segment stenosis and for patients in
whom a bypass was not an option. The advent of stents
and the technological advances made in this area have
allowed endovascular options to be offered in every vas-
cular bed. In high-risk patients in whom an open abdom-
inal aortic aneurysm (AAA) repair was believed to be too
dangerous, a stent graft can be placed with very low
procedural risk.
Although believed by many to have few complications
because procedures are performed through sheaths in the
femoral artery, endovascular procedures are still an opera-
tive procedure in the vascular system and can be associated
with similar complications as well a new variety of com-
plications unique to catheter-based interventions. Some of
these complications are described in this chapter.
INDICATIONS
Peripheral arterial disease
OPERATIVE STEPS
Step 1 Access and contrast
Step 2 Angioplasty and stenting
Step 3 Endovascular AAA repair
Operative Procedure
Contrast Toxicity
Performance of catheter-based techniques requires the use
of contrast agents and digital subtraction imagery. Con-
trast toxicity can affect many organs and have a profound
detrimental effect. Many minor reactions of contrast have
been reduced with the lower-osmolality agents now avail-
able.1 One of the major adverse effects of contrast agents
is nephrotoxicity, which is generally dened as a rise in the
creatinine of greater than 25% above baseline in the
absence of other inciting events2 (grade 1 complication).
The event usually occurs within 48 hours of the proce-
dure. For most patients, it is nonoliguric and resolves over
time. The most important risk factor for the development
of contrast-induced nephropathy is preexisting renal insuf-
ciency. Other contributing factors are dehydration, dia-
betes, and the amount of contrast used.
The treatment for contrast-induced nephrotoxicity is
hydration, with less than 1% of patients progressing on to
the need for dialysis. Prevention of nephrotoxicity is
accomplished via the following methods: hydration,
especially in patients with renal insufciency, has been
shown to be the most effective preventive measure; N-
acetylcysteine has been shown to reduce the risk of
contrast-induced nephropathy in patients with renal
insufciency3; and alkalinization of the urine has also
been found to be benecial in patients with renal
insufciency.4
Access Site Complications
Although simplistic in nature, the puncture and access
of the arterial system can lead to serious complications.
In infrainguinal procedures, the common femoral artery
is accessed above the bifurcation of the supercial
femoral artery (SFA) and the profunda femoris artery
(PFA) and below the inferior epigastric artery. The access
site is identied via uoroscopic imaging and palpation of
the femoral artery.5 The ideal location is over the femoral
head6 (Fig. 631). After the procedure, manual pressure
is applied to achieve hemostasis of the puncture site or
a closure device is used to mechanically seal the area.
Numerous complications can occur during this part of the
procedure.
High Arterial Puncture (Fig. 632)
Consequence
Uncontrolled bleeding and retroperitoneal bleeding
can occur because ineffective pressure can be applied
to this area. A signicant amount of blood can be lost,
especially if the patient has received heparin or anti-
platelet agents.
Grade 1/3 complication
 652 SECTION X: VASCULAR SURGERY

Figure 631 Proper position of

femoral access site. A, Subtracted
view displays access below the infe-
rior epigastric artery and above the
bifurcation. B, View with landmarks
displays access in the common
A B femoral artery over the femoral
head.

unstable, the need for direct surgical repair of the artery

is necessary.
Prevention
Using anatomic landmarks and preprocedural
imaging.

Low Arterial Puncture

Consequence
Pseudoaneurysm (PSA) formation and potential distal
ischemia can occur with a low puncture.
Grade 1/2/3 complication
Repair
PSA can be monitored if it is small, and many will
spontaneously regress. More recently, duplex-guided
thrombin injection has been used to treat this compli-
cation. If the patient has distal ischemia from injury to
the SFA or the PFA, surgical exploration and repair are
mandated.
Prevention
Figure 632 High arterial puncture. Note the entrance of the
As described earlier and recognizing the problem prior
sheath near the upper border of the femoral head.
to removing the sheath.

Poorly Angled Puncture

Repair
The retroperitoneum will often tamponade the bleed- Consequence
ing, but the patient will have pain and likely require If the angle of the access needle is greater than 60
blood transfusions. In some instances, if the patient is degrees, the guidewire and sheath may not pass easily.

This can cause injury to the back wall of the artery and
hematoma formation as well as potential dissection of
the artery.
Grade 1/2 complication
Repair
Removing the needle and manual compression and
thorough pulse examination after compression.
Prevention
The needle should not be angled at greater than 60
degrees during the access.
Access Site Thrombosis
Consequence
Development of acute ischemia of the involved limb.
Grade 3/4 complication
Repair
Immediate surgical exploration and repair of the
affected artery.
Prevention
When applying manual pressure, excessive force should
be avoided to allow blood ow to continue and deposit
platelets over the access site. If a closure device is used,
the artery should be inspected uoroscopically for the
presence of disease and adequate caliber.
Angioplasty and Stenting
The technological advances such as the lower-prole
devices have allowed this procedure to become a fairly
routine practice in vascular surgery. The insertion of a
balloon into a diseased artery allows for expansion of the
lumen. However, this lesion may recoil; therefore, placing
a stent to prevent recoil may be advantageous in certain
vascular beds. The procedure is conducted after obtaining
access, as described previously. The guidewire is then
passed through the lesion and maintained in this position
as the angioplasty balloon is passed and expanded. Stents
are balloon-expandable (stent premounted on a balloon)
or self-expanding (may require postdeployment angio-
plasty) and are placed over the diseased area.7
Arterial Perforation
Consequence
Arterial perforation can occur during balloon angio-
plasty and distally as well with the guidewire perforat-
ing the wall of the vessel. Depending on the vascular
bed, this may lead to minor discomfort or life-
threatening hemorrhage.
Grade 2 or possibly 4 complication depending
on vascular bed (i.e., aortoiliac artery) or if not
recognized
63 ENDOVASCULAR INTERVENTIONS 653
Repair
If the perforation is noted in an extremity vessel, place-
ment of the balloon over the site and inated to the
lowest pressure to allow sealing of the injury usually
resolves the issue. Anticoagulation should be reversed
as well. If this is not the case, placement of a covered
stent is necessary. In vascular beds such as the iliac
artery, control of the bleeding with a balloon will not
likely control the perforation; therefore, placement of
a covered stent is the treatment.8 In a renal angioplasty,
distal perforation can be controlled with coil emboliza-
tion. If these methods fail, surgery is mandated.
Prevention
Attempt to properly size vessels; if the patient experi-
ences discomfort during the procedure, deate the
balloon and evaluate. To prevent guidewire perfora-
tion, the tip of the wire should always be visualized.
Arterial Dissection
Consequence
Passing a guidewire (particularly a hydrophilic wire)
into the subintimal plane and failure to reenter the true
lumen can lead to dissection of the artery, as can angio-
plasty of a severely diseased vessel. If not recognized,
this can lead to thrombosis of the treated vessel.9
Grade 1/2 complication
Repair
Placement of a stent over the dissected area effectively
treats most dissections.
Prevention
Dissections are frequent occurrences and can be pre-
vented and treated adequately by placement of stents.
The key element is recognizing a dissection.
Embolization
Consequence
Embolization of calcic plaque or an endovascular
device (e.g., a stent) is always a potential hazard with
any intervention. The potential for ischemia is present,
particularly in the case of severely diseased run-off for
the lower extremity or end-organ ischemia in organs
such as the kidney.
Grade 1/2 complication
Repair
Fundamentally, there are two options: (1) removing
the embolized material or (2) deploying, or trapping,
it in a safe location. If the embolic material is from a
diseased vessel or thrombus, the use of large ush
catheter to aspirate the material or, if necessary, a
mechanical thrombectomy device can usually be suc-
cessful. The use of snares to capture free balloons or
guidewires is often effective. If a stent is free, attempts
to cannulate it and expand it in a more peripheral
 654 SECTION X: VASCULAR SURGERY

location such as the iliac artery or placing a larger stent
to trap it is a useful technique. Ultimately, it may be
necessary to perform an open surgical procedure to
remove the device directly from the vessel if the prior
endovascular salvage techniques are unsuccessful and
the device is impeding critical blood ow.
Prevention
Attention to the devices and inspecting balloons and
stents prior to using them as well as careful endovascu-
lar techniques can usually prevent this uncommon
occurrence.
Endovascular AAA Repair
Endovascular AAA (EVAR) has been a major advance in
vascular surgery since its approval by the U.S. Food and
Drug Administration in 1999. It has allowed for treat-
ment of AAA in patients who would not likely have been
offered an open repair owing to other comorbidities. It is
also a minimally invasive approach to aortic reconstruction
that offers signicantly fewer acute complications and a
much speedier recovery. Because several devices are now
available, the volume of EVAR has increased and patients
with anatomic characteristics that earlier would have been
prohibitive are now offered the option of EVAR using
adjunctive techniques to facilitate its use.10 The basic pro-
cedure for the modular devices is as follows: access via
bilateral femoral arteries; delivery of the main body and
ipsilateral limb of the device below the renal arteries; can-
nulation of the contralateral limb and delivery and deploy-
ment of this limb; placement of iliac extensions if necessary;
and angioplasty of the proximal and distal seal zones.
Although much less invasive than traditional open repair,
EVAR still constitutes an operation on the aorta and its
complications can be devastating.
should be placed to occlude the aorta as well as within
the iliac artery portion and open repair performed.
Prevention
As with any case, but in particular, with EVAR, preop-
erative planning is the key, and careful examination of
the access sites can prevent this problem.
Device Fatigue
Consequence
Fracture of the stent or material fatigue can lead to
devastating problems and endoleaks that can result in
perfusion of the aortic sac that was previously excluded
by the endovascular graft. This acute repressurization
of the old AAA sac can lead to acute rupture.
Grade 2/3 complication
Repair
Recognition and detailed evaluation with high-deni-
tion computed tomography with reconstruction and an
arteriogram to identify the source of failure, which can
potentially be treated with another stent graft. If endo-
vascular option is not possible, explanting the device
and proceeding with open repair.
Prevention
This problem is difcult to prevent and requires ongoing
surveillance of patients with endografts.
Endoleaks
Classication of endoleaks is as follows:
Type I: ow into the aneurysm sac via the proximal or
distal attachment site (Fig. 633)

Access Failure
Complication
As opposed to the standard sheaths for peripheral inter-
ventions, the EVAR devices are much larger, with
sheaths ranging from 22 to 26 Fr for the main body
and 12 to 20 Fr for the contralateral limb. If the iliac
artery is less than 7.5 mm, there may be difculty in
delivering the device, which may lead to iliac artery
injury (e.g., perforation, occlusion, dissection) or
avulsion.
Grade 2/3/4 complication

Repair
If the device will not pass easily, the alternative is to
use an iliac conduit in which a retroperitoneal incision
is made and a 10-mm Dacron graft is then sewn to the
iliac bifurcation and the device delivered through this.
If a portion of the artery has a focal stenosis, angioplasty Figure 633 Type I endoleak from distal migration of endografts.
may be sufcient. If iliac avulsion is noted, a balloon Note the large aneurysm sac on angiography.
 63 ENDOVASCULAR INTERVENTIONS 655

Consequence
Type I and III endoleaks represent continued aneurysm
sac exposure to aortic pulsatility and pressure. Aneu-
rysm rupture is likely if untreated.
Grade 2/3/5 complication
Type II endoleaks are generally self-limiting and most
close spontaneously. Close follow-up is necessary, and
intervention is indicated for evidence of aneurysm
growth.
Grade 1/2 complication
Type IV endoleaks are rare and most disappear in the
early follow-up period.
Grade 1/2 complication12
Repair
For type I endoleaks, immediate repair at the time of
the initial procedure is warranted if the defect can be
accurately identied and treated with endovascular
means. This is usually accomplished via balloon expan-
sion of the proximal and distal attachment sites, place-
Figure 634 Type II endoleaks likely emanating from a patent
lumbar. Note that there is only a small amount of contrast within ment of additional cuffs over this area, or placement
the sac that is predominantly thrombosed. of a balloon-expandable stent to seal the area. Type II
endoleaks can be monitored, but if the AAA enlarges
during follow-up, treatment is necessary. This can
include transarterial coil embolization or direct trans-
lumbar aortic embolization.13 Type III endoleaks, if at
graft attachment sites, are treated with additional endo-
graft coverage of the graft defect.
Prevention
Recognition of the problem at the time of the comple-
tion arteriogram and during follow-up, as well as pre-
operative planning and accurate sizing particularly of
the proximal and distal seal zones, are the most impor-
tant methods of preventing this.

REFERENCES

1. Barrett BJ, Carlisle EJ. Meta-analysis of the relative

Figure 635 Type III endoleaks from displacement of the left iliac
limb. This area was subsequently treated with a covered stent with
resolution of the endoleaks.
Type II: circulation within the sac from aortic branches
such as the lumbar arteries or inferior mesenteric artery
(Fig. 634)
Type III: reperfusion of the aneurysm sac from either a
hole in the fabric of the graft or disjunction of modular
components (Fig. 635)
Type IV: ow through porous fabric material11
nephrotoxicity of high- and low-osmalality iodinated
contrast media. Radiology 1993;188:171178.
2. Murphy SW, Barrett BJ, Parfrey PS. Contrast nephropa-
thy. J Am Soc Nephrol 2000;11:171182.
3. Tepel M, Van Ger Giet M, Schwarzeld C, et al. Preven-
tion of radiographic-contrast-agent-induced reductions in
renal function by acetylcysteine. N Engl J Med 2003;343:
180184.
4. Merten GJ, Burgess WP, Gray LV, et al. Prevention of
contrast-induced nephropathy with sodium bicarbonate.
JAMA 2004;291:23282334.
5. Schneider PA (ed). How to get in: percutaneous vascular
access. In Endovascular Skills: Guidewire and Catheter
Skills for Endovascular Surgery, 2nd ed. New York:
Marcel Dekker, 2003; pp 530.
6. Rupp SB, Vogelzang RL, Nemeck AA, et al. Relationship
of the inguinal ligament to pelvic radiographic landmarks:
anatomic correlations and its role in femoral arteriography.
J Vasc Interv Radiol 1993;4:409413.
 656 SECTION X: VASCULAR SURGERY
7. Schneider PA (ed). Balloon angioplasty: minimally invasive
autologous revascularization. In Endovascular Skills:
Guidewire and Catheter Skills for Endovascular Surgery,
2nd ed. New York: Marcel Dekker, 2003; pp 201216.
8. Scheinert D, Ludwig J, Steinkamp. Treatment of cath
induced iliac artery injuries with self-expanding endografts.
J Endovasc Ther 2000;7:213220.
9. Ansel GH. Endovascular complications of angioplasty and
stenting. In Complications in Vascular Surgery. New York:
Marcel Dekker; 2004; pp 597614.
10. Fairman RM, Velazquez O, Baum R, et al. Endovascular
repair of aortic aneurysms: critical events and
adjunctive procedures. J Vasc Surg 2001;33:1226
1232.
11. Deaton DH, Makaroun MS, Fairman RM. Endoloeak:
predictive value for aneurysm growth at 3 years. Ann Vasc
Surg 2002;16:3742.
12. Beebe HG. Endoleak. In Towne JB, Hollier LH (eds).
Complications in Vascular Surgery. New York: Marcel
Dekker, 2004; pp 659682.
13. Baum RA, Carpenter JP, Golden MA, et al. Treatment of
type 2 endoleaks after endovascular repair of abdominal
aortic aneurysms: comparison of transarterial and trans-
lumbar techniques. J Vasc Surg 2002;35:2329.
Section XI
THORACIC SURGERY
M. Blair Marshall, MD
Good people are good because theyve come to wisdom through failure. We get very
little wisdom from success, you knowWilliam Saroyan

64
Bronchoscopy: Flexible and Rigid;
Esophagoscopy: Flexible and Rigid;
Mediastinoscopy; and
Anterior Mediastinotomy
John C. Kucharczuk, MD

choscopy can be easily performed in awake patients as

Bronchoscopy: Flexible
and Rigid
INTRODUCTION
In the late 1890s, Gustav Killian used a rigid tube to
remove an impacted piece of bone from the right main
stem of an awake 63-year-old man. Twenty years later
in Philadelphia, Chevalier Jackson popularized extensive
examination of the airways using rigid bronchoscopy.
Jacksons techniques were effective, however, they required
specialized training; only a few physicians possessed the
skills required to perform the procedure safely. Today,
awake rigid bronchoscopy is rarely practiced. Neverthe-
less, rigid bronchoscopy performed with the patient under
general anesthesia remains a valuable diagnostic and ther-
apeutic tool for the modern thoracic surgeon. It is irre-
placeable in certain circumstances.
The advent of the exible bronchoscope in the 1970s
revolutionized the eld of bronchoscopy. Flexible bron-
well as in those who are anesthetized. Flexible broncho-
scopes can be used for both diagnostic and therapeutic
interventions and are available in a number of sizes and
specialized congurations designed for particular applica-
tions. Working channels from 1.2 mm up to 3.2 mm
allow for aspiration of secretions as well as deployment of
a number of instruments into the airway under direct
vision.
The modern thoracic surgeon must be an expert
bronchoscopist comfortable with both exible and rigid
bronchoscopy. He or she must be able to choose the
approach and instrument most appropriate to a given
clinical situation.
BRONCHOSCOPY STEPS
Step 1 Select procedure (rigid vs. exible)
Step 2 Select appropriate anesthesia (topical vs.
general)
Step 3 Institute monitoring
 658 SECTION XI: THORACIC SURGERY

Distal ventilation holes

Fiberoptic
connection

Ventilation
side port

Figure 641 The most commonly used rigid bronchoscopes of

varying sizes. Note the ventilatory attachment and the side ports.

Step 4 Supply supplemental oxygen

Step 5 Perform procedure
Step 6 Recover patient
Figure 642 Computed tomography (CT) image of impending
airway obstruction from a chondrosarcoma (arrow) of the trachea.
BRONCHOSCOPY PROCEDURE

Select the Appropriate

Bronchoscopy Technique
The greatest pitfall in bronchoscopy is the inappropriate
choice of one technique (exible or rigid) over another.
Currently, rigid bronchoscopy is performed exclusively in
anesthetized patients and allows for the examination of
the trachea and proximal airway only. Flexible bronchos-
copy, conversely, can be performed in awake or anesthe-
tized patients and allows for examination of the airway
down to the subsegmental level.
RIGID BRONCHOSCOPY
Rigid bronchoscopy should be performed in the operating
room with the patient under general anesthesia. Specic
applications for rigid bronchoscopy are listed later. Rigid
bronchoscopes come in a variety of diameters and lengths,
as shown in Figure 641. They are sized according to
the outside diameter. Figure 642 shows the computed
tomography (CT) scan of a patient with a tracheal mass
and impending respiratory obstruction. This patient is an
ideal candidate for rigid bronchoscopy for diagnosis and
palliative relief of the airway obstruction using a coring
technique. The nal pathology is this case was a tracheal
chondrosarcoma.
INDICATIONS
Removal of foreign bodies
Evacuation of tracheal stenosis
Placement of nonexpandable stents
Control of massive hemoptysis
Evaluation of tracheobronchial mobility
Evaluation of airway invasion or adherence by esophageal
tumors
Palliation of airway obstruction by tumor (coring out)
Inappropriate Patient for Rigid Bronchoscopy
The preoperative assessment of patients undergoing rigid
bronchoscopy includes examination of the neck and oral
cavity. Severe cervical arthritis with a contracted neck
makes rigid bronchoscopy difcult. Poor dentition and
loose teeth are at risk during rigid bronchoscopy, and
removable dental work such as bridges and dentures
should be taken out prior to the procedure. The presence
of a mature tracheostomy, conversely, is not a contraindi-
cation to rigid bronchoscopy. The tracheostomy device
can be removed and the patient intubated with the rigid
scope from above or, in some circumstances, directly
through the stoma, with particular care being taken to
avoid injury to the posterior membranous portion of the
trachea. Likewise, rigid bronchoscopy can be performed
through the mature stoma in patients who have under-
gone total laryngectomy.
Consequence
Inability to position the patient appropriately, resulting
in an inability to safely perform the procedure. Com-
plications can range from minor damage to the denti-
tion to life-threatening perforation of the pharynx or
airway.
Grade 15 complication
Repair
Select an alternative method for airway visualization
and intervention.
 64 BRONCHOSCOPY: FLEXIBLE AND RIGID
Prevention
Adequately evaluate the patient preoperatively. Do
not attempt rigid bronchoscopy on patients with a
xed cervical spine or an inability to be positioned
appropriately.
Inadequate Cooperation between Surgeon
and Anesthesiologist
The performance of rigid bronchoscopy with the patient
under general anesthesia requires close coordination
between the anesthesiologist and the surgeon. While the
anesthesiologist institutes the appropriate monitoring and
intravenous access, the surgeon should prepare the rigid
bronchoscope along with its light source and supporting
hardware. During routine rigid bronchoscopy, general
anesthesia is induced with a combination of intravenous
and inhalation anesthetics. Secretions are aspirated from
the posterior pharynx, and the patient is mask-ventilated.
A muscle relaxant is then administered to allow easier
placement of the rigid bronchoscope. Patients with large
mediastinal masses or near-complete obstructing tracheal
tumors represent a particular challenge and, as such,
require special anesthetic consideration. Placement of
these patients in a supine position or administration of
general anesthesia with a muscle relaxant can lead to com-
plete airway obstruction and life-threatening hypoxemia.
In these patients, the airway should rst be anesthetized
with local agents. Patients should remain in a somewhat
upright position while general anesthesia is slowly induced
with intravenous agents. During this phase, the anesthe-
siologist assists the patients spontaneous ventilation. Use
of muscle relaxants should be avoided until the airway is
secure. Once anesthetized, the patient should be quickly
positioned and intubated with the rigid scope. Ventilation
through the anesthesia circuit connected to the side port
of the ventilating scope can then begin. If a nonventilating
scope is used, insufation of oxygen via a Venturi appara-
tus can be used to maintain oxygenation.
Consequence
Inadequate control of the airway resulting in hypercar-
bia, hypoxemia, and death.
Grade 3/4/5 complication
Repair
Both the surgeon and the anesthesiologist must under-
stand the conduct of the procedure and work together
as a team. It is helpful to review the planned procedure
with the entire operating room team as well as to have
a contingency plan in case of a loss of the airway.
Prevention
The procedure should be performed by a cohesive
group of anesthesiologists, surgeons, and nurses. The
entire team must understand the procedure before
starting.
659
1
Inability to Place the Rigid Bronchoscope
When the surgeon is ready to introduce the rigid bron-
choscope, the patient should be positioned supine with
the neck slightly exed (snifng position). The surgeon
stands behind the patients head, secretions are suctioned
from the posterior pharynx, and tooth guards are placed.
The surgeon controls the patients head by gripping the
maxilla with the middle and ring ngers of the left hand.
The index nger and thumb of this same hand hold the
scope in the manner in which one holds a pool stick. The
right hand grasps the scope at the level of the eyepiece.
The instrument is introduced with the bevel down and
advanced until the epiglottis is visualized. The scope is
placed just under the leading edge of the epiglottis, which
is then gently elevated to reveal the vocal cords. Elevation
is achieved by the use of the left thumb. Use of the
patients teeth or gums as a fulcrum to elevate the epiglot-
tis results in damage to the teeth and must be avoided.
One should avoid advancing the scope further than 1 cm
beyond the tip of the epiglottis because this places the
scope beyond the larynx.
When the vocal cords are visualized, the scope is rotated
90 to the right and advanced into the trachea. Once in
the trachea, the scope is rotated back to its original posi-
tion. The supporting pillow can then be removed from
behind the head and the table headboard can be lowered
to extend the neck. Ventilation is begun either through
the side port with an eyepiece in place or via the Venturi
apparatus if a nonventilating scope is being used.
Consequence
Inability to insert the rigid bronchoscope can result
from a number of causes: inadequate training, inability
to position the patient appropriately, and inadequate
visualization owing to secretions or blood. Complica-
tions can range from having to convert to an alternative
technique, minor damage to dentition, life-threatening
perforation of the pharynx or airway, and even loss of
airway control and death.
Grade 15 complication
Repair
If the patient is an inappropriate candidate for rigid
bronchoscopy or the operator is not sufciently trained,
an alternative method for airway visualization and
intervention should be selected.
Prevention
Adequately evaluate the patient preoperatively.
Inadequate Visualization of the Airway
The patients head should be turned to the side opposite
that which you wish to examine. When passing the scope
into the right main stem, for example, the patients head
should be turned slightly to the left. We typically hold
ventilation and remove the eyepiece when advancing the
scope. If closer inspection of the airway is required, a
 660 SECTION XI: THORACIC SURGERY

Hopkins rod telescope is passed through an adapter on

the main channel of the rigid scope. These telescopes
provide magnication as well as a variety of angled views.
If telescopes are not available, a exible bronchoscope can
be passed through the rigid scope.
Consequence
Advancing a rigid bronchoscope with inadequate
visualization of the airway will likely result in airway
perforation, necessitating thoracotomy and complex
reconstruction.
Grade 35 complication
Repair
The best strategy is not to advance a rigid broncho-
scope in the airway unless a clear lumen can be seen
ahead.
Prevention
The patients head is manipulated to align the long axis
of the airway with the scope, allowing the scope to be
passed with clear visualization of the distal lumen.

Recover the Patient

After rigid bronchoscopy, the patient is recovered from
general anesthesia in a postanesthesia care unit. Those
patients undergoing laser ablation of an obstructing lesion
or relief of airway obstruction by a coring technique
utilizing the rigid bronchoscope should be hospitalized
and observed overnight to ensure that an adequate airway
has been achieved.
FLEXIBLE BRONCHOSCOPY
Unlike rigid bronchoscopy, awake exible bronchoscopy
can be performed in the outpatient setting for a variety
of diagnostic and therapeutic indications, as listed later.
Unfortunately, beroptic bronchoscopes are delicate
instruments; they require specialized training for cleaning,
maintenance, and storage, as shown in Figure 643.
INDICATIONS
Examination of airway to subsegmental level
Aspiration of secretions
Mucosal brushings
Biopsy of endobronchial lesions
Deployment of expandable airway stents
Removal of small foreign bodies
Transbronchial needle biopsy
Outpatient awake exible bronchoscopy is performed in
a specially designed endoscopy suite. The suite must
include a supplemental oxygen supply, pulse oximetry,
cardiac monitoring, and intubation equipment to be
used in the event of an airway emergency. Supplemental
oxygenvia either nasal cannula or face mask with a spe-
cially designed opening to allow for the passage of the
Figure 643 Storage unit for exible bronchoscopes to prevent
damage.
bronchoscopeshould be provided to all patients under-
going bronchoscopy. Adequate monitoring of the awake
patient includes pulse oximetry and heart rate monitoring.
Most patients have an intravenous line in place; however,
with properly administered topical anesthesia, intravenous
sedation is rarely required. Figure 644 shows the bron-
choscopic view of a patient with an endobronchial lesion.
This patient is an ideal candidate for outpatient diagnostic
exible bronchoscopy with endobronchial biopsy prior to
embarking on denitive management.
Awake bronchoscopy during the postoperative period
is frequently performed on the thoracic surgery ward. The
most common indication for postoperative bronchoscopy
is atelectasis due to mucus plugging. Well-timed therapeu-
tic bronchoscopy in these patients can often prevent more
serious complications such as pneumonia and reintuba-
tion. To facilitate the bedside procedure, bronchoscopy
carts stocked with a exible bronchoscope, a light source,
suction tubing, bite blocks, oxygen masks, local anesthet-
ics, pulse oximetry, and emergency airway equipment
should be readily available. Carts should be inventoried
and maintained daily by an adequately trained respiratory
therapist. Having this simple cart available will minimize
the frustration encountered when attempting a procedure
on an awake patient without appropriate equipment. At
our institution, we typically use a standard adult broncho-
scope with an external diameter of 5.9 mm for awake
procedures.
 64 BRONCHOSCOPY: FLEXIBLE AND RIGID
Figure 644 Obstruction of the right upper lobe orice by
tumor.
Flexible bronchoscopy with the patient under general
anesthesia should be performed in the operating room
under the supervision of an anesthesiologist. Monitoring
should include pulse oximetry, noninvasive blood pressure
monitoring, and three-lead electrocardiographic monitor-
ing. Following the induction of general anesthesia, direct
laryngoscopy is performed and an endotracheal tube is
placed. Tube position is conrmed by auscultation, obser-
vation of the chest, and end-tidal CO2 monitoring. In the
adult patient, an 8.0-mm endotracheal tube should be
used. This tube size allows ventilation via a bronchoscopy
adapter during the use of a standard 5.9-mm outside
diameter (OD) exible bronchoscope. The 5.9-mm OD
exible bronchoscope is preferred because its working
channel of 2.8 mm is large enough to allow aspiration
of thick secretions without becoming clogged. The use of
smaller endotracheal tubes with smaller bronchoscopes is
often frustrating because of difculty in clearing secretions
in order to obtain an adequate view. The pediatric bron-
choscope has an OD of 3.5 mm and a working channel
of only 1.2 mm. In the case of laser bronchoscopy and
other specialized uses, a 6.2-mm OD scope with a 3.2-mm
working channel can be used. If possible, a 9.0-mm endo-
tracheal tube should be used in these patients.
Select Appropriate Anesthesia
Inadequate Topical Anesthesia for Awake
Flexible Bronchoscopy
Adequate topical anesthesia is paramount to the perfor-
mance of awake exible bronchoscopy. Anesthesia should
begin with the administration of nebulized lidocaine (5 ml
661
of 1% lidocaine solution) by a respiratory therapist. The
posterior pharynx, tonsillar pillars, and soft palate are then
sprayed with 1% lidocaine. Next, 2 to 5 ml of a 2%
lidocaine solution is injected transtracheally through
the cricothyroid membrane with a 21-gauge needle. This
maneuver causes the patient to cough but results in topical
anesthesia of the airway. Finally, a bite block is placed in
the mouth, and the bronchoscope is introduced through
the mouth and advanced down to the level of the vocal
cords. One milliliter of a 4% lidocaine solution is then
sprayed through the working channel of the broncho-
scope onto each vocal cord under direct vision. The scope
is removed and the patient is encouraged to cough. At
this point, local anesthesia is complete and awake bron-
choscopy can be easily performed with satisfactory patient
comfort. Intravenous sedation can lead to hypoxemia,
hypercarbia, and hypotension and should thus be avoided.
With properly administered local anesthesia, patients
remain comfortable throughout the procedure and subse-
quent intravenous sedation is rarely required. After awake
exible bronchoscopy, patients should be monitored with
pulse oximetry for a short period to ensure that oxygen-
ation is satisfactory. A chest x-ray should be obtained
to rule out pneumothorax, lobar collapse, and novel
inltrates. Because the posterior pharynx and vocal cords
remain anesthetized, patients should remain on nothing
by mouth for 3 to 4 hours after the procedure to minimize
the risk of aspiration.
Consequence
Inability to complete the procedure owing to patient
discomfort.
Grade 1/2 complication
Repair
Suspend the procedure and provide adequate topical
anesthesia.
Prevention
Generous topical analgesia for all patients undergoing
awake bronchoscopy. Avoid intravenous sedation, which
can contribute to secretion-management difculties.
PROCEDURE OUTCOMES
Complication rates for both rigid and exible bronchos-
copy should be low. Bleeding dyscrasias should be
addressed prior to the procedure, particularly if biopsy
is planned. The majority of complications surrounding
awake exible bronchoscopy are related to preprocedural
intravenous sedation. As discussed previously, this issue
can be avoided altogether with the proper application of
local anesthesia and avoidance or minimal use of intrave-
nous sedation. This cannot be stressed enough when
dealing with frail or elderly patients, in whom signicant
hypoxemia must be avoided. Particularly tenuous patients
 662 SECTION XI: THORACIC SURGERY
are probably better off undergoing elective intubation
followed by therapeutic bronchoscopy rather than strug-
gling through a difcult awake bronchoscopy. Avoiding
hypoxemia during rigid bronchoscopy requires teamwork
and coordination between the anesthesiologist and the
surgeon.
CONCLUSIONS
Both rigid and exible bronchoscopy are invaluable tools
for the thoracic surgeon. Whereas exible bronchoscopy
has become the norm, situations arise that demand the
use of rigid bronchoscopy. As such, thoracic surgeons
must obtain sufcient training so that they can perform
both procedures with condence.
Esophagoscopy: Flexible
and Rigid
INTRODUCTION
Esophagoscopy has developed along lines similar to those
of bronchoscopy. Initial examinations of the esophagus
were performed with rigid metal tubes, the forerunners of
the current rigid esophagoscope. The advent of beroptic
technology revolutionized the eld of diagnostic esopha-
goscopy. The exible esophagoscope is easy to insert in
the sedated or anesthetized patient, and minimal training
is required to become quite procient in its use. Con-
versely, rigid esophagoscopy requires an anesthetized
patient along with specialized insertion skills. Improper
insertion of a rigid esophagoscope can result in esophageal
perforation, a highly morbid event.
ESOPHAGOSCOPY STEPS
Step 1 Select technique (exible vs. rigid)
Step 2 Select appropriate anesthesia (sedation vs.
general)
Step 3 Institute monitoring
Step 4 Perform procedure
Step 5 Recover patient
ESOPHAGOSCOPY PROCEDURE
Select the Appropriate Technique
Flexible beroptic esophagoscopy is ideal for outpatient
diagnostic procedures because it can be performed safely
in an outpatient endoscopy suite on a sedated patient. The
procedure allows for examination of the entire esophagus,
stomach, and proximal duodenum. A variety of instru-
ments are available for deployment via the working
channel: biopsy forceps, snares, brushes, cautery wires,
dilation balloons, and laser bers.
Conversely, rigid esophagoscopy must be performed in
the operating room on an intubated patient under general
anesthesia. Because of its large lumen, the rigid esopha-
goscope is ideally suited for the visualization and extrac-
tion of impacted foreign bodies. Its superior suction
capacity makes it extremely useful in the case of severe
esophageal bleeding; conversely, exible scopes can easily
be overcome by signicant bleeding. The rigid esophago-
scope also allows for better visualization of the difcult
to view masses located just below the cricopharyngeus.
Finally, compared with the exible beroptic esoph-
agoscope, the rigid esophagoscope is inexpensive and
durable.
The improperly inserted esophagoscope, whether ex-
ible or rigid, can result in pharyngeal or esophageal per-
foration. Insertion of a exible scope in the sedated patient
requires only placement of a bite block to protect the
scope, a simple forward jaw lift, and smooth insertion of
the esophagoscope into the cervical esophagus with gentle
air insufation.
The rigid esophagoscope is a rigid metal tube with a
ared tip and a thin beroptic rod for illumination. These
are available in a number of lengths, as shown in Figure
645. Inserting a rigid esophagoscope is signicantly more
challenging than inserting a exible esophagoscope. The
patient should be intubated and tooth guards placed to
protect dentition. If dentures or dental bridges are present,
they should be removed prior to the procedure. The
patients head should be positioned in the snifng position
with slight neck extension. Because of the positioning
requirements, rigid esophagoscopy is contraindicated in
patients with unstable cervical spines, restricted jaw move-
ment, or severe kyphoscoliosis. The presence of thoracic
arch aneurysms is a relative contraindication to rigid
esophagoscopy. Once the patient is properly positioned,
the scope is placed through the open mouth and passed
through the posterior pharynx into the proximal esopha-
gus. The esophagus must be entered gently because the
cervical esophagus is at high risk for perforation during
this phase. If resistance is encountered after passing
through the cricopharyngeus, deation of the endotra-
cheal tube cuff, which sits just anterior in the tracheal
lumen, can often provide easier passage. Once the scope
Figure 645 Rigid esophagoscopes of varying lengths and luminal
diameters.
 64 BRONCHOSCOPY: FLEXIBLE AND RIGID
has been inserted into the cervical esophagus, the patients
neck should be fully extended to align the rigid scope with
the longitudinal axis of the esophagus. In order to avoid
perforation, forward advancement of the rigid scope must
be done gently with the distal lumen always in sight.
Inability to Insert the Scope
Consequence
Insertion of an esophagoscope, either exible or rigid,
must be done with the utmost care. Because of the
high-pressure zone at the upper esophageal sphincter,
the cervical esophagus is at high risk for perforation
during incorrect scope insertion.
Grade 15 complication
Repair
Select the appropriate method for esophageal visualiza-
tion and intervention.
Prevention
Adequately evaluate patients preoperatively. Do not
attempt rigid esophagoscopy on patients with a xed
cervical spine or an inability to be positioned appropri-
ately. Always advance the esophagoscope with a clear
view of the distal lumen.
PROCEDURE OUTCOMES
Both rigid and exible esophagoscopy should have low
complication rates. This being said, patients with severe
chest pain, subcutaneous emphysema, pneumothorax,
pleural effusion, or fever after either rigid or exible
esophagoscopy must be suspected of having an iatrogenic
perforation. An immediate esophagogram should be per-
formed in each and every one of these patients to deter-
mine the site and extent of the damage and to guide the
subsequent management of these injuries.
CONCLUSIONS
Both rigid and exible esophagoscopy are invaluable tools
for the esophageal surgeon. Whereas exible esophagos-
copy has become the norm, situations arise that demand
the use of rigid esophagoscopy. As such, the practicing
esophageal surgeon should be condent with the use of
both procedures.
Mediastinoscopy
INTRODUCTION
Mediastinoscopy was rst described in the late 1950s.
Since that time, it has become a routine diagnostic pro-
cedure for patients with lung cancer. It is currently widely
663
used as a diagnostic tool for a variety of other mediastinal
abnormalities occurring in the paratracheal and subcarinal
regions.
By its very nature, mediastinoscopy violates all of
the basic surgical tenets. The procedure is performed
with limited exposure, around the great vessels with no
vascular control. Nevertheless, in competent hands, it
can be performed safely, providing invaluable diagnostic
information.
MEDIASTINOSCOPY STEPS
Step 1 Patient selection
Step 2 General anesthesia
Step 3 Positioning
Step 4 Perform procedure/conrm pathology
Step 5 Recover patient
MEDIASTINOSCOPY PROCEDURE
Selecting the Appropriate Patient
for Mediastinoscopy
Many patients are referred for mediastinoscopy inappro-
priately. Patients present with a variety of anterior medi-
astinal, aortopulmonary window, and posterior mediastinal
abnormalities. It is vital that the surgeon performing
mediastinoscopy understand the limitations of the proce-
dure and the relationship of vital vascular structures to the
mediastinoscopy plane.
Standard cervical mediastinoscopy can assess both the
right and the left paratracheal areas as well as the sub-
carinal space. Figure 646A shows a CT scan of the chest
from a patient with paratracheal, subcarinal, and hilar
adenopathy. The paratracheal and subcarinal nodes are
accessible by mediastinoscopy (see Fig. 646B). The hilar
nodes are not accessible (see Fig. 646C), and an attempt
at biopsy via cervical mediastinoscopy will result in life-
threatening hemorrhage owing to azygous vein and/or
pulmonary artery injury.
Mediastinoscopy is performed under general anesthesia
with the patients neck fully extended. Proper positioning
is critical. An inatable bag placed under the patients
shoulders will provide adequate extension (Fig. 647A).
The patient shown in Figure 647B is properly positioned
and ready for the procedure. An inability to ex the
neck is a contraindication to the procedure. Prior cardiac
surgery does not affect the procedure because the medi-
astinoscopy plane descends posterior to the pericardium.
A history of a prior tracheostomy may make cervical dis-
section more difcult but is not a contraindication. Medi-
astinoscopy cannot be performed in patients with a current
tracheostomy device in place or in those with tracheal
stomas due to laryngectomy. Prior neck and anterior
mediastinal radiation are relative contraindications to the
procedure because the mediastinal plane may or may not
be obliterated.
 664 SECTION XI: THORACIC SURGERY
A
B Figure 647 A, Proper patient positioning for cervical mediasti-
Figure 646 A, Paratracheal adenopathy (arrow) accessible by
mediastinoscopy. B, Subcarinal adenopathy accessible with the
mediastinoscope (single arrow). Right hilar adenopathy (arrowheads)
not accessible with the mediastinoscope.
Inappropriate Patient Selection
Consequence
Inappropriate patient selection for mediastinoscopy
can have disastrous consequences. Patients must have
cervical neck exibility in order to be properly posi-
tioned for the procedure to be performed safely. Prior
mediastinal surgery is a relative contraindication and
must be evaluated on a case-by-case basis.
Grade 25 complication
Repair
In patients who are not candidates for mediastinoscopy
but require mediastinal sampling, alternative techniques
such as transbronchial needle aspiration should be
considered.
Prevention
Adequately evaluate patients preoperatively. Do not
attempt mediastinoscopy on patients with a xed cervi-
cal spine or an inability to be positioned appropriately.
Neck extended
Inflatable bag
A
noscopy with the patients shoulders resting on an inatable bag
and the neck extended. B, The patient has been prepared and
draped for cervical mediastinoscopy.
Perform the Procedure/Conrm
the Pathology
Bleeding
A standard cervical mediastinoscope is illustrated in Figure
648. Light is supplied to the tip of the scope via a ber-
optic cable. As such, any signicant bleeding results in
lights out with total loss of visualization. Clearly, the
best method for dealing with bleeding during mediasti-
noscopy is avoidance. The mediastinum is replete with
small perinodal vessels that can cause problematic bleed-
ing. A special insulated suction/cautery device (Fig. 649)
is used to coagulate small bronchial vessels. Lack of insu-
lation at the distal tip of the device allows for conduction
of current to the tip of the device only. Suction allows for
aspiration of blood to clear the eld. Cautery should not
be used in the left paratracheal space because it can result
in damage to the left recurrent nerve, which courses
through the left tracheal esophageal groove. A specialized
aspirating needle (Fig. 6410) should be used to avoid
biopsy of vascular structures such as the aorta, pulmonary
 64 BRONCHOSCOPY: FLEXIBLE AND RIGID
Figure 648 Standard scope used for cervical mediastinoscopy.
Non-insulated tip
Cautery connection
Suction port
Figure 649 Insulated suction cautery device used for dissection
through the mediastinoscope as well as to control hemorrhage for
small vessels.
Biopsy forceps
Aspirating needle
Figure 6410 A variety of biopsy forceps used through the
mediastinoscope, as well as the long aspiration needle. The latter
is useful for differentiating nodal tissue from blood vessels.
artery, superior vena cava, and azygous vein. The nodes
themselves should be sampled with a gentle twisting
of the biopsy forceps. Forceful pulling of nodal tissue
will result in disruption of major associated vascular
structures.
665
Consequence
Bleeding during mediastinoscopy ranges from minor
to life threatening, depending upon the bleeding site.
Small bleeding bronchial vessels can obscure visualiza-
tion but are usually easily controlled with cautery.
Major vascular injuries can lead to exsanguination.
Grade 35 complication
Repair
Should major bleeding occur during mediastinoscopy,
the mediastinum should be packed immediately. A long
E-tape or vaginal packing can be inserted directly into
the scope. The scope can then be slowly withdrawn as
the packing is advanced. Once the scope is removed,
digital compression should be applied. Because bleed-
ing most commonly results from injury to the azygous
vein or pulmonary artery, packing easily controls
these low-pressure systems. Once successful packing is
achieved, blood should be ordered and adequate large-
bore venous access conrmed. Having a functioning
arterial line is helpful. When these safeguards are in
place, median sternotomy is performed and the injury
is identied and repaired under direct visualization.
Always resist the urge to convert to a thoracotomy; all
vascular injuries caused by mediastinoscopy can be
repaired via sternotomy, some are not reparable via a
thoracotomy approach. Once the injury is repaired,
staging can be completed by obtaining the appropriate
additional lymph node biopsies. In the event that a
lung resection was planned for the same sitting and the
patient is found to be stage-appropriate, the resection
can be performed through the sternotomy.
Prevention
The best method for dealing with bleeding during
mediastinoscopy is avoidance.
Pneumothorax
Occasionally, the right pleural space is inadvertently
breached during mediastinoscopy. Typically, the incision
can be closed over a red rubber tube; the anesthesiologist
then applies a Valsalva breath to the ventilatory circuit as
the tube is removed. In cases in which the lung has been
damaged or biopsied and an ongoing air leak exists, a
chest tube is required.
Consequence
A small pneumothorax caused by entrance into the
pleural space is inconsequential. Parenchymal lung
damage with ongoing air leak requires placement of a
chest tube.
Grade 13 complication
Repair
When the pleura is entered with no lung injury, the
pleural air can be evacuated by closing the incision
around a small red rubber tube, giving a large positive-
pressure breath on the anesthesia circuit and then
removing the tube. In this case, a small, stable
 666 SECTION XI: THORACIC SURGERY
pneumothorax on a postoperative lm is of no signi-
cance. Conversely, if there has been lung injury with
an ongoing air leak, a chest tube must be placed and
remain in place until the air leak resolves.
Prevention
Careful attention to detail and knowledge of the
anatomy should allow one to avoid inadvertent
entrance into the pleural space.
PROCEDURE OUTCOMES
Mediastinoscopy continues to be the single best method
for staging the mediastinum in patients with lung cancer.
In well-trained hands, the procedure can be performed
safely with very accurate results. The overall complication
rate for mediastinoscopy should be less than 1%.
Anterior
Mediastinotomy
INTRODUCTION
The anterior mediastinotomy or Chamberlain procedure,
as originally described, provides access to the aortopulmo-
nary lymph nodes. These nodes are not assessable with
standard cervical mediastinoscopy. In our current under-
standing of lung cancer, however, patients with left-sided
lung cancers and aortopulmonary window nodal metasta-
sis (stations 5 and 6) enjoy a much better outcome with
surgical resection than those patients with stage IIIa
disease based on left paratracheal metastasis. Thus, ante-
rior mediastinotomy is infrequently performed at present
in the staging of lung cancer. However, it remains a very
useful technique to sample anterior mediastinal masses.
Figure 6411 shows the CT scan of a patient with a large
anterior mediastinal mass. This lesion is appropriate for
sampling by anterior mediastinotomy.
Left mammary
vessels
Mass
Figure 6411 CT scan demonstrates an anterior mediastinal
mass appropriate for a Chamberlain procedure.
ANTERIOR MEDIASTINOTOMY STEPS
Step 1 Patient selection
Step 2 Select anesthesia (general vs. local)
Step 3 Perform procedure
Step 4 Intraoperative conrmation of diagnostic mate-
rial (working with pathologist)
Step 5 Recover patient
ANTERIOR MEDIASTINOTOMY
PROCEDURE
There are very few contraindications to anterior mediasti-
notomy in patients with anterior mediastinal masses.
Signicant experience and cooperation with the anesthe-
siologist is required in patients with very large anterior
mediastinal masses and airway compression. Controversy
has always surrounded the biopsy of a well-dened mass
believed to be an encapsulated thymoma because of
the concern for pleural dissemination. When condent on
clinical and radiographic grounds that the lesion is a well-
encaspsulated thymoma, it should be resected without a
biopsy. In less-clear cases or in cases in which lymphoma
is a consideration, biopsy via anterior mediastinotomy
is performed. In general, we avoid needle biopsies of
anterior mediastinal masses because our pathologist and
hematopathologist prefer large amounts of tissue for his-
tology and special studies. This practice, however, is
largely institution-dependent.
An important subset of patients are those with medias-
tinal germ cell tumors. They do not require biopsy
for diagnosis; the diagnosis is made by serum markers
including -human chorionic gonadotropin and -
fetoprotein levels. Surgery in this cohort of patients is
reserved for resection of residual masses following
systemic treatment.
Anesthesia (General vs. Local)
The anterior mediastinotomy procedure can be performed
with the patient under local or general anesthesia. In
patients with very large masses, the major concern is
airway compression with muscle paralysis; in difcult cases,
spontaneous ventilation is maintained throughout the
procedure. A rigid bronchoscope should be available in
case it is required to emergently establish an airway. Obvi-
ously, both the surgeon and the anesthesiologist must
cooperate and have signicant experience to safely perform
the procedure on patients with very large masses.
Loss of Airway
Consequence
Loss of airway during induction of general
anesthesia.
Grade 25 complication
 64 BRONCHOSCOPY: FLEXIBLE AND RIGID
Repair
Have a rigid bronchoscope available and assembled in
the operating room to establish an airway in an emer-
gent situation.
Prevention
Adequately evaluate the patient preoperatively with the
anesthesia team. Maintain spontaneous respirations in
a somewhat upright position until the airway has been
secured.
Perform the Procedure
Incorrect Incision
The standard incision is made overlying the second costal
cartilage. This incision is 3 cm in length and starts at the
sternal boarder. The angle of Louis (sternal angle) is the
palpable landmark on the sternum that marks the level of
the second costal cartilage. This position corresponds to
the narrowing of the sternum seen on consecutive axial
CT scan images as the manubrium transitions to the body
of the sternum. The incision can be made over any costal
cartilage that overlies the abnormality. However, the
second costal cartilage always serves as the landmark and
is used as a reference point for locating masses that occur
lower in the mediastinum. Figure 6412 shows a patient
being readied for anterior mediastinotomy; the intent is
to enter the superior mediastinum through the bed of
the left second intercostal cartilage. The sternal notch
and angle of Louis are marked for reference. If the mass
is very large, the intercostal muscles are divided and the
biopsy is performed between the ribs. In situations in
which better exposure is required, the anterior perichon-
drium is scored with cautery and a periosteal elevator is
used to perform an extraperichondrial resection of a 3-cm
segment of costal cartilage. The posterior perichondrium
Figure 6412 Patient being readied for a Chamberlain proce-
dure (anterior mediastinotomy); the sternal notch and angle of
Louis have been highlighted and the bed of the left second costal
cartilage is marked (2).
667
is opened with a scalpel, allowing direct access to the
anterior mediastinum.
Consequence
Inability to locate and biopsy the lesion.
Grade 13 complication
Repair
In difcult situations, a lighted mediastinoscope can be
placed through the incision to help visualize the target
lesion.
Prevention
Correlate the location of the incision with the preop-
erative chest CT scan and known anatomic landmarks,
especially the sternal angle
Bleeding
The most common cause of bleeding during anterior
mediastinotomy is inadvertent damage to the mammary
artery. The mammary arteries run close to the sternal
border. Knowing the anatomy allows the surgeon to iden-
tify and protect the vessels by gently sweeping them later-
ally. If the mammary artery is injured, bleeding is controlled
with ligation. Complete transaction of the artery may be
difcult to control because the cut ends have a tendency
to retract. In these cases, the ends must be located and
ligated or clipped; cautery is not sufcient.
Consequence
Signicant blood loss.
Grade 14 complication
Repair
Locate and ligate both ends of a transected mammary
artery.
Prevention
Mobilize and sweep the mammary artery laterally to
avoid injury.
Pneumothorax
The causes of pneumothorax during anterior mediasti-
notomy are (1) inadvertent entrance into the pleural cavity
and (2) injury to the lung with creation of an air leak.
Distinguishing between the two mechanisms is crucial
because the management is quite different. During dissec-
tion, the pleural membrane should be swept laterally with
the mammary vessels. If the pleural cavity is inadvertently
entered, the incision is closed over a red rubber catheter
(Fig. 6413) and a Valsalva breath is used to evacuate the
air. The tube is removed while the positive-pressure breath
is held by the anesthesiologist. The nal stitch is tied to
create an airtight seal. In the case of injury to the under-
lying lung with a persistent air leak, a chest tube is placed.
Although the tube can be placed through the incision, this
is generally uncomfortable and cumbersome for a chest
 668 SECTION XI: THORACIC SURGERY
Figure 6413 Red rubber catheter placed though the skin
incision evacuating an iatrogenic pneumothorax during anterior
mediastinotomy.
tube. When a chest tube is required, I recommend placing
it through a separate incision in a traditional site.
Consequence
A small pneumothorax caused by entrance into the
pleural space is inconsequential. Parenchymal lung
damage with ongoing air leak requires placement of a
chest tube.
Grade 13 complication
Repair
When the pleura is entered with no lung injury, the
pleural air can be evacuated by closing the incision
around a small red rubber tube, giving a large positive-
pressure breath on the anesthesia circuit and then
removing the tube. In this case, a small, pneumothorax
on a postoperative lm is of no signicance. Con-
versely, if there has been lung injury with an ongoing
air leak, a chest tube must be placed and remain in place
until the air leak resolves.
Prevention
The pleural membrane should be swept laterally with
the mammary vessels to avoid entering the pleural
cavity and/or inadvertent lung injury.
Intraoperative Conrmation of
Diagnostic Material
Nondiagnostic Material
Intraoperative review of the biopsy material with a pathol-
ogist familiar with mediastinal pathology is mandatory.
Several of the lymphomas generate a brisk tissue reaction,
and initial samples may show only brosis whereas deeper
samples conrm the pathology. I usually review a touch
preparation and frozen section on the portion of the initial
biopsy specimen with the pathologist. The pathologist
cannot make the nal diagnosis based on these initial
studies. She or he must, however, conrm the presence of
an abnormality (not just brous tissues or necrosis) and
the adequacy of tissue for appropriate studies to obtain a
diagnosis. Nothing is more frustrating than nding out 3
days after the procedure that more tissue is needed.
Consequence
A nondiagnostic procedure and need for additional
invasive procedures.
Grade 13 complication
Repair
Do not conclude the procedure until adequate diag-
nostic material has been obtained.
Prevention
Mandatory intraoperative review of touch preparations
and frozen sections with a qualied pathologist or
hematopathologist to conrm adequate diagnostic
tissue.
PROCEDURE OUTCOMES
The anterior mediastinotomy procedure is a safe and effec-
tive way to sample anterior mediastinal masses. The com-
plication rate is low, and the diagnostic rate should be
high. In stable patients, the procedure is performed on an
outpatient basis. Patients with large masses and concern
for airway compression are admitted and their pathology
rushed so that treatment may begin within 36 hours.
SUGGESTED READINGS
Bronchoscopy: Flexible and Rigid
1. Alvarez F, Burger C, Grinton S, et al. Competencies in
pulmonary procedures. Chest 2004;125:800801.
2. British Thoracic Society guidelines on diagnostic exible
bronchoscopy. Thorax 2001;56(suppl 1):i1i21.
3. Lukomsky GI, Ovchinnikov AA, Bilal A. Complications of
bronchoscopy: comparison of rigid bronchoscopy under
general anesthesia and exible beroptic bronchoscopy
under topical anesthesia. Chest 1981;79:316321.
Esophagoscopy: Flexible and Rigid
4. Gaer JA, Blauth C, Townsend ER, Fountain SW. Method
of endoscopic esophageal intubation using a rigid esopha-
goscopy. Ann Thorac Surg 1990;49:152153.
 64 BRONCHOSCOPY: FLEXIBLE AND RIGID
5. Glaws WR, Etzkorn KP, Wenig BL, et al. Comparison of
rigid and exible esophagoscopy in the diagnosis of
esophageal disease: diagnostic accuracy, complications, and
cost. Ann Otol Rhinol Laryngol 1996;105:262266.
6. Brinster CJ, Singhal S, Lawrence L, et al. Evolving
options in the management of esophageal perforation.
Ann Thorac Surg 2004;77:14751483.
Mediastinoscopy
7. Hammoud ZT, Anderson RC, Meyers BF, et al. The
current role of mediastinoscopy in the evaluation of
thoracic disease. J Thorac Cardiovasc Surg 1999;118:894
899.
8. Lemaire A, Nikolic I, Petersen T, et al. Nine-year single
center experience with cervical mediastinoscopy: complica-
tions and false negative rate. Ann Thorac Surg
2006;82:11851189; discussion 11891190.
669
9. Kumar P, Yamada K, Ladas GP, Goldstraw P. Mediasti-
noscopy and mediastinotomy after cardiac surgery: are
safety and efcacy affected by prior sternotomy? Ann
Thorac Surg 2003;76:872876; discussion 876877.
Anterior Mediastinotomy
10. McNeill TM, Chamberlin JM. Diagnostic anterior
mediastinotomy. Ann Thorac Surg 1966;2(4):532539.
11. Patterson GA, Piazza D, Pearson FG, et al. Signicance of
metastatic disease in subaortic lymph nodes. Ann Thorac
Surg 1987;43:155159.
12. Watanabe M, Takagi K, Aoli T, et al. A comparison of
biopsy through a parasternal anterior mediastinotomy
under local anesthesia and percutaneous needle biopsy for
malignant anterior mediastinal tumors. Surg Today
1998;28:10221026.
65
Lobar Resections
Todd S. Weiser, MD and Scott J. Swanson, MD
INTRODUCTION
Lung cancer remains the most common cause of cancer
death in the United States for both men and women.
Approximately 170,000 deaths each year are attributable
to lung cancer, surpassing the number of deaths due to
the next four most common cancers combined.1 The
majority of these cases are due to nonsmall cell lung
carcinoma (NSCLC). Most patients present with advanced
locoregional or disseminated disease, and despite advances
in multimodality treatment of this disease, the 5-year sur-
vival remains 10% to 12%. However, when patients with
lung cancer are diagnosed at an early stage, the overall
5-year survival may exceed 70% to 80%.2
Complete surgical resection remains the cornerstone
for curative therapy of NSCLC.3,4 The rst successful
resection for lung cancer, a pneumonectomy, was per-
formed by Evarts Graham in 1933. An anatomic resection,
preferably a lobectomy or pneumonectomy and, in some
instances, segmentectomy, is the standard treatment for
stage I or II NSCLC.5 Between 20% and 30% of all patients
with new lung cancers have disease that is amenable to
surgical treatment. The remainder of patients present with
locally unresectable disease or with distant metastases.
Neoadjuvant strategies involving chemotherapy, thoracic
radiation, or both can render some of these patients sub-
sequently resectable. Nonanatomic wedge resections are
used for diagnostic purposes and, in rare instances, for the
local control of lung cancer.
The rst description of thoracoscopy appeared in
1910, when pleural adhesions were lysed with the use
of a cystoscope.6 With the advent of selective bronchial
intubation, the use of thoracoscopy expanded from
addressing pleural processes to performing bullectomies
and wedge resections, and it is now utilized in the surgi-
cal treatment of lung cancer with anatomic lung resec-
tions. Video-assisted thoracic surgery (VATS) lobectomy
has been employed in the treatment of lung cancer since
1993.7,8
No large, prospective, randomized studies have been
reported comparing video-assisted lobectomy with those
performed via the traditional open approach. There are,
however, some small, nonrandomized studies comparing
outcomes with these two surgical approaches.9,10 Data
from these series, as well as others,7,8,1113 demonstrate that
in experienced hands, lobectomy by either approach is
associated with minimal morbidity and mortality. The
perioperative mortality rate associated with a VATS lobec-
tomy is less than 1%, which compares favorably with the
open approach. Video-assisted thoracoscopic anatomic
resections are certainly more technically demanding than
those carried out via a conventional approach. There have
been no prognostic variables identied to date that are
able to predict intraoperative complications in patients
undergoing pulmonary lobectomy.
The VATS operation consists of individual hilar ligation
via three to four small incisions without rib spreading.
This anatomic lobectomy should replicate the identical
oncologic principles as those achieved via traditional
thoracotomy.14 That is, the surgeon resects the tumor
with negative margins performing individual vascular and
bronchial ligation and division, with a complete hilar node
dissection. Furthermore, a mediastinal lymph node dissec-
tion, or sampling, is performed, as appropriate. Certain
aspects in VATS lobectomies, such as avoiding rib spread-
ing and/or the use of a rib retractor, are emphasized with
the goal of improving the patients postoperative experi-
ence. Cosmetic aspects such as smaller scars (the largest
incision is usually 5 to 8 cm) are also important. One
variant, the video-assisted simultaneously stapled lobectomy,
does not employ individual hilar ligation. In essence, it is
a different operation and is not discussed in this chapter.
Nevertheless, some surgeons have achieved excellent
results with this technique.15
INDICATIONS
Primary lung neoplasms
Pulmonary metastases not amenable to wedge resec-
tion owing to anatomic considerations
Benign lung tumors not amenable to wedge resection
owing to anatomic considerations
Congenital anomalies such as arteriovenous malforma-
tions and pulmonary sequestrations
Infectious or inammatory pathology
 672 SECTION XI: THORACIC SURGERY

OPERATIVE STEPS

Step 1 Positioning and incision/thoracoscopic port

placement
Step 2 Lung mobilization
Step 3 Isolation and division of pulmonary arterial and
venous branches
Step 4 Fissure completion
Step 5 Bronchial division
Step 6 Lymph node dissection
Step 7 Closure

OPERATIVE PROCEDURE 5th or 6th

Incision/Thoracoscopic Port Placement
Intercostal Bundle Injuries
After the patient is placed in a lateral decubitus position,
the chest is typically entered through a serratus-sparing,
limited posterolateral thoracotomy in either the fourth or
the fth interspace for traditional open lobectomies. To
facilitate exposure and avoid unintentional rib fracture
with retraction, we routinely remove a small segment of
posterior rib in a subperiosteal fashion with a rib cutter.
To perform a thoracoscopic lobectomy, two ports and
an access incision are usually required (Fig. 651). This is
an incision 5 cm or less that aids in the hilar dissection
and through which the specimen is extracted via an endo-
scopic bag. Avoiding rib spreading is the key element in
VATS lobectomy to prevent postoperative pain and trauma
to the intercostal nerve bundles responsible for the post-
thoracotomy pain syndrome.
Port placement may vary slightly owing to patient body
habitus, location of the tumor, and surgeon preference.
However, optimal port placement is important for safe
and successful resection. The rst port is the camera port,
and it is usually placed within the seventh or eighth inter-
costal space. Whether it is in the anterior, middle, or
posterior axillary line depends on the level of the dia-
phragm as seen from a review of a preoperative chest x-ray,
on the location of the pathology, and on left- versus right-
sided procedures. Ideally, this port should provide views
of the anterior and posterior hilum and should align with
the major ssure. We almost exclusively use a 30 thora-
coscope. It provides optimal views, not afforded by a 0
scope, particularly during the difcult dissection around
the superior hilum. The anterior port should be placed
right over the hilum because this will be used as the
access/utility port. Dissection of both the hilum and the
ssure will be performed through this port. This incision
is initially 1 to 2 cm. It is not extended to 5 centimeters
in length until we have decided to proceed with the VATS
lobectomy. The port is usually created anterior to the
latissimus dorsi in the fourth intercostal space for upper
lobectomies and in the fth intercostal space for lower
lobectomies. The third port is usually in the fourth or fth
intercostal space, either inferior or posterior to the scapu-
interspace
4th interspace
5 cm incision
7th interspace
Figure 651 The three thoracoscopic port incisions for comple-
tion of a video-assisted thoracic surgery (VATS) right upper lobec-
tomy. The 5-cm access incision is placed in the fourth intercostal
space and in the anterior axillary line. The camera port is placed in
the seventh interspace, and the posterior port is located in the
fourth intercostals space, posterior to the tip of the scapula. (From
Nicastri DG, Yun J, Swanson SJ. VATS lobectomy. In Sugarbaker
DS, Bueno R, Zellos L (eds): Adult Chest Surgery: Concepts and
Procedures. New York: McGraw-Hill, Inc., 2006. Reprinted with
permission.)
lar tip. This port usually serves as the lung retraction port.
Hemostasis is very important when creating the ports
because bleeding from the port sites onto the camera, and
onto the surgical eld, during the procedure is a nuisance
and can signicantly prolong the operation.
Post-thoracotomy pain is believed to be caused by rib
spreading with resultant trauma to the intercostal nerve.
Benedetti and coworkers16 analyzed supercial abdominal
reexes in patients after posterolateral thoracotomy and
concluded that increased incisional pain intensity may be
due to intercostal nerve impairment. Many studies evalu-
ated the intensity of acute pain after minimally invasive
thoracic surgery. In particular, Landreneau and associ-
ates17 performed a study comparing 165 patients who had
a lung resection through a posterolateral thoracotomy
with 178 patients who had a VATS resection.17 At 1-year
follow-up, there was a signicant difference in overall pain,
pain intensity scores, and shoulder function between the
two groups, favoring a VATS approach.
 65 LOBAR RESECTIONS 673

Consequence
Intercostal nerve trauma may be associated with chronic
pain syndromes such as intercostal neuralgias.
Grade 1/2 complication
Repair
Once the intercostal nerve has been injured, little can
be done to repair it. Usually, such an injury is not
recognized until subsequent postoperative visits. At
this time, the patient complains of a chronic pain syn-
drome that does not improve with healing.
Prevention
Avoiding pressure on the intercostal bundle while using
the thorascopic instruments is the best way to prevent
injury to these structures.

Lung Mobilization
Phrenic Nerve Injury
Once access to the chest cavity is obtained, a thorough A
exploration is performed. The pleural surface is inspected
for tumor implants and any adhesions are lysed sharply
with cautery or with an ultrasonic cutting and coagulation
device. Extensive pleural adhesions are not a contraindica-
tion to proceed with a VATS lobectomy. Careful and
complete adhesiolysis allows full mobility of the lung.
Retraction of the lung is critical to being able to complete
the resection.
The discovery of tumor invasion into the chest wall is
a contraindication to a VATS approach because it requires
en-bloc chest wall resection. Digital palpation of the
tumor and lung is performed through the anterior/access
port to conrm the location and presence of the tumor
and also to rule out additional unsuspected nodules or
pathology not identied on preoperative studies. In VATS
resections, ipsilateral mediastinal lymph node sampling
is performed, especially if mediastinoscopy was not per-
formed earlier. If N2 disease is discovered on frozen
section, the VATS resection is aborted and the patient is
B
treated with neoadjuvant therapy. If a preoperative tissue
diagnosis has not been determined, a wedge or core biopsy Figure 652 A, The right upper lobe is retracted posteriorly,
is performed initially, followed by lobectomy if frozen exposing the superior pulmonary vein (thin arrow). The right phrenic
section reveals carcinoma. nerve is visualized (thick arrow) as it lies anterior to the pulmonary
hilum. The nerve should be carefully mobilized away from the
Consequence anterior hilum to avoid inadvertent injury. B, The left upper lobe
Circumferential evaluation of the hilar structures should is retracted posteriorly. The left phrenic nerve (thin arrow) is visu-
then be performed to determine lung resectability. The alized and dissected anteriorly during isolation of the left superior
salient goal of lobectomy is to ligate and divide the pulmonary vein (thick arrow).
major vessels and bronchus with clear margins. To
achieve this, the hilar pleura is opened. Anteriorly, the
course of the phrenic nerve should be identied and preoperative respiratory function who have undergone
the pleura should be opened posterior to this structure phrenic nerve transfer for brachial plexus injuries.18 In
(Fig. 652). Inadvertent injury of the phrenic nerve these patients with normal lung function, there was no
leads to paralysis of the ipsilateral hemidiaphragm. This evidence of diminished pulmonary function parameters
complication has not been adequately described in the within 1 year. One could anticipate signicant pulmo-
literature for patients undergoing pulmonary lobec- nary compromise and complications with phrenic nerve
tomy. The effects of unilateral phrenic nerve transec- injuries in patients undergoing pulmonary lobectomy.
tion have been studied in young patients with normal Most of these patients have baseline pulmonary dys-
 674 SECTION XI: THORACIC SURGERY

function and will also have reduced pulmonary capacity

associated with lung resection.
Grade 2/3 complication

Repair
Direct neural repair is not recommended. If signicant
postoperative respiratory insufciency exists, potential
surgical interventions can be performed to improve
respiratory function. Diaphragmatic plications via tho-
racoscopic and open techniques have been developed
to achieve this goal.19,20 In a recent study of 22 patients
with unilateral diaphragm paralysis, VATS diaphrag-
matic plication resulted in signicant improvements in
patients functional status, pulmonary spirometry, and
dyspnea scores.19 There was no operative mortality, and
the mean length of hospital stay was 3.7 days. Long-
Figure 653 The right lower lobe is retracted anteriorly, placing
term follow-up in a similar group of patients undergo- the right inferior pulmonary ligament in tension. This maneuver
ing plication via a thoracotomy found durable results allows proper visualization of the esophagus (arrow) and avoids
exceeding 10 years.20 Phrenic nerve pacing with dia- esophageal injury during division of the pulmonary ligament.
phragmatic electrodes has also resulted in clinical
improvements in ventilator-dependent, quadriplegic
patients.21 This technique has not been employed for ageal stent placement can be considered as an alterna-
patients with unilateral phrenic nerve dysfunction. tive approach in selected cases.

Prevention
Early identication and preservation of the phrenic
nerve should allow the surgeon to avoid this potentially
devastating injury.
Esophageal Injury
The inferior pulmonary ligament is typically divided in all
pulmonary lobectomies. This is performed during upper
lobectomies, allowing the lower lobe to potentially
decrease the amount of intrathoracic space associated with
lung resection. Access to the inferior pulmonary vein for
lower lobectomies is facilitated by division of the pulmo-
nary ligament. This structure is a remnant of the embryo-
logic pleural fold and lies in close proximity to the inferior
pulmonary vein and esophagus.
Consequence
Unrecognized esophageal injury can lead to a delayed
presentation of esophageal perforation and sepsis.
Esophagopleural stulas, although uncommon, have
been most frequently described after pneumonectomy
for both benign and malignant diseases.22 This can be
secondary to injury directly onto the esophagus or to
its vascular supply from extensive dissection.
Grade 3/4/5 complication
Repair
If recognized intraoperatively, esophageal injuries from
electrocautery or sharp dissection can be repaired with
layered repair and vascularized tissue buttress. Delayed
recognition of esophageal injuries often requires control
of infection, hyperalimentation, and either closure of
the injury or possibly esophagectomy. Covered esoph-
Prevention
The lower lobe is gently grasped and retracted cepha-
lad. The pulmonary ligament is placed on adequate
tension and then divided with electrocautery. Care
must be taken to identify the underlying esophagus and
inferior pulmonary vein (Fig. 653). Adequate expo-
sure should prevent esophageal injury as well as possible
life-threatening hemorrhage associated with damage to
the inferior pulmonary vein.
Technical Aspects of Specic Lobectomies
Performed utilizing Thoracotomy
An intimate understanding of the anatomy of the hilar
structures is crucial to avoid the surgical pitfalls of pulmo-
nary lobectomy. Specically, one must have a comprehen-
sive mastery of the course of the main pulmonary artery
and its branches. These are delicate, thin-walled vessels
requiring meticulous dissection to avoid life-threatening
injury.
Right Upper Lobectomy
The sequence in dissection and ligation is based on the
anatomic setting and convenience. Initial dissection is
undertaken at the anterior hilum. The mediastinal pleura
is opened posterior to the phrenic nerve, and this plane is
continued superiorly and posteriorly between the lung
and the azygous vein. The lung is retracted anteriorly to
expose the right main stem bronchus at the bifurcation of
the upper lobe bronchus and bronchus intermedius. The
plane between these two structures is developed bluntly.
The upper lobe branches of the superior pulmonary
vein are identied and ligated. The draining veins of the

Figure 654 When performing a right upper lobectomy, care
must be taken to identify and preserve the middle lobe of the
pulmonary vein (arrow).
middle lobe must be identied as well to prevent uninten-
tional division (Fig. 654). In the anterior hilum, the main
pulmonary artery is then dissected as it exits the medias-
tinum inferior to the azygous vein. The truncus anterior
artery, with its apical and anterior branches, is isolated and
divided with a vascular stapler or suture ligature.
The upper lobe bronchus is then divided. This can be
performed either with a stapling device using a thick tissue
staple load or with a scalpel and subsequent absorbable
suture closure. With the truncus anterior branch of
the pulmonary artery already divided, pulmonary arterial
injury is avoided. Attention must be given during retrac-
tion of the upper lobe at this point because the posterior
recurrent pulmonary artery branch remains. Avulsion inju-
ries can occur if excessive tension is exerted in this area.
The remaining ssures are then completed with stapling
devices. The bronchial stump is tested for its integrity
under saline immersion.
Right Middle Lobectomy
The dissection begins at the intersection of the oblique
and horizontal ssures to expose the interlobar pulmonary
artery. The parenchyma of the middle lobe is then retracted
anteriorly with the identication of the middle lobe pul-
monary artery, which may be present as a single trunk or
as two separate vessels. After pulmonary artery division,
the middle lobe pulmonary venous supply is isolated in
the anterior hilum. The middle lobe bronchus is the
remaining structure after the division of pulmonary venous
outow. Draining lymphatics are swept up toward the
specimen, and the bronchus is divided.
Right Lower Lobectomy
Attention is initially given to identifying and exposing the
interlobar pulmonary artery at the junction of the oblique
and horizontal ssures. The superior segmental artery to
65 LOBAR RESECTIONS 675
the lower lobe arises posteriorly and across from the cor-
responding middle lobe branch. Division of the superior
segmental branch is followed with ligation of the arterial
branches to the basilar segments. The inferior pulmonary
vein is identied after the inferior pulmonary ligament is
divided using electocautery. Level 9 lymph nodes should
be swept up into the specimen. The posterior mediastinal
pleura is opened to allow effective clearance of the inferior
pulmonary vein from the lower lobe bronchus. A vascular
stapler is used to divide the inferior pulmonary vein once
preservation of middle lobe venous drainage is ensured.
Fissure completion is performed, leaving the lower lobe
attached only by its bronchus. Care must be taken not to
compromise the airway to the middle lobe when dividing
the lower lobe bronchus.
Left Upper Lobectomy
Dissection is initially undertaken at the anterior hilum
with the lung retracted posteriorly. The mediastinal pleura
is incised over the left main pulmonary artery after it
courses beneath the aortic arch. Care is taken to identify
and preserve the phrenic nerve anteromedially and the
vagus nerve with its recurrent laryngeal branch, which
courses under the aortic arch.
Attention is then given to exposing the interlobar
pulmonary artery within the major ssure. Once this is
achieved, careful isolation of the upper lobe pulmonary
arterial branches is undertaken. There is considerable
anatomic variability in the number of separate arterial
branches to the left upper lobe. It may be necessary to
isolate and divide the superior pulmonary vein to the
upper lobe in order to safely gain access to the rst pul-
monary artery branch. The left upper lobe bronchus is
divided once all of the pulmonary arterial branches have
been addressed.
Left Lower Lobectomy
The posterior hilum is approached initially with exposure
of the interlobar pulmonary artery in the ssure. Dissec-
tion, isolation, and subsequent division of the arterial
branch to the superior segment are performed. Next, the
basilar trunk arterial branches are identied and divided.
Attention must be given to preserving the lingular seg-
mental arterial branches that arise in close proximity to
those supplying the basilar segments (Fig. 655). The
ssure can now be safely completed with a stapler.
The inferior pulmonary ligament is then divided, expos-
ing the lower border of the inferior pulmonary vein. The
mediastinal pleura is opened to the anterior and posterior
hila, enabling isolation of the inferior vein. This must be
meticulously freed from the membranous wall of the lower
lobe bronchus. Once mobilized, the vein is divided with
the use of a stapling device. Occasionally, the left superior
and inferior veins will join to form a common trunk before
draining into the left atrium. This rarely occurs in the
 676 SECTION XI: THORACIC SURGERY

Figure 655 Attention must be given to identifying the pulmo-

nary arterial branches to the lingular segments (thin arrow) when A
performing a left lower lobectomy. These lingular branches lie in
close proximity to those supplying the basilar segments (thick
arrows).

pulmonary venous system of the right lung. One must

ensure preservation of the superior pulmonary vein when
performing a left lower lobectomy (Fig. 656).
The lobe is now attached only by the lower lobe bron-
chus, which is then transected after nodal tissue is swept
up into the specimen. The upper lobe bronchial orice
should not be narrowed with the application of the stapler.
Patency of the upper lobe bronchus can be ensured by
having the anesthesiologist gently inate the left lung
prior to ring the stapling device.

Technical Aspects of Specic Lobectomies

Performed utilizing the VATS Approach B

The principles of video-assisted thoracoscopic lobectomies
do not differ from those that pertain to traditional open
procedures. Pulmonary arteries, veins, and bronchi must
be separately isolated and divided. Standard lymph node
dissection practices are also adhered to with VATS tech-
niques. All resected specimens are placed in a heavy lapa-
roscopic extraction sac to prevent tumor seeding of the
port and are removed through the anterior access incision
without any rib spreading. The conduct of the operation
for the different lobes is essentially the same and is
described later with some caveats.
Right Upper Lobectomy
We usually place our camera port in the seventh intercos-
tal space and the anterior axillary line. This provides good
visualization of the anterior and superior hilum, the area
Figure 656 A, The left inferior pulmonary ligament has been
divided and circumferential dissection performed around the infe-
rior pulmonary vein (arrow). B, Further inspection reveals that what
had been previously identied as the inferior pulmonary vein was,
in fact, a common venous trunk (thin arrow) emptying into the left
atrium. Dissection and isolation of the left inferior pulmonary vein
(thick arrow) was completed, followed by vascular division.
of most hazardous dissection. The access port is usually
located in the fourth intercostal space anteriorly, with care
taken not to injure the long thoracic nerve and avoiding
breast tissue in women. The posterior working/utility
port is placed inferior or posterior to the scapula tip. The
orientation of this port should provide a right-angle
conguration between instruments in the access and
working ports.
After the initial exploration, dissection is begun in the
anterior hilum. The right upper lobe is grasped gently
 65 LOBAR RESECTIONS 677

A C

Stapler

Camera

Retractor

B
Figure 657 A, The right superior pulmonary vein (thin arrow) has been dissected off of the underlying right pulmonary artery (thick
arrow). Care must be taken during this aspect of right upper lobectomy to avoid catastrophic bleeding from an injured proximal pulmonary
artery. B, Placement of the thoracoscopic vascular stapler through the posterior working port for division of the right superior pulmonary
vein. The pulmonary artery lies underneath this structure. Attention must be given to minimizing torsion of the stapler to prevent injury
to the underlying artery. C, The endoleader is attached to the stapling device to gently guide this instrument across the vein. The red
rubber catheter must be dislodged from the stapler before it is closed and red. This maneuver can be performed with an endo-Kitner
or ring forceps. (B, From Nicastri DG, Yun J, Swanson SJ. VATS lobectomy. In Sugarbaker DS, Bueno R, Zellos L [eds]: Adult Chest
Surgery: Concepts and Procedures. New York: McGraw-Hill, Inc., 2006. Reprinted with permission.)

with ring forceps and retracted posteriorly. This maneuver
creates excellent exposure to the anterior hilum. The supe-
rior pulmonary vein is isolated rst by dividing its pleural
covering with a harmonic scalpel, Pearson scissors, and/or
endo-Kitners. The plane between the vein and the under-
lying pulmonary artery must be carefully developed (Fig.
657A). An oiled 2-0 silk tie is then looped around the
superior pulmonary vein. The endo-leader, an 8-Fr red
rubber catheter, may be utilized to enable safe passage of
the vascular stapler around the vein (see Fig. 657B and
 678 SECTION XI: THORACIC SURGERY

A C

Retractor

Stapler
Camera

7C).23 The stapler is introduced through the posterior
port, providing the most effective angle for stapler applica-
tion and division of the vein. Once this is completed, the
truncus anterior branch of the right pulmonary artery and
its variable number of segmental branches are exposed
(Fig. 658A). These are isolated individually or as one
trunk, depending on their conguration and accessibility.
They are then divided individually or as one trunk, using
an endovascular stapler. The endoleader can be used to
safely guide the stapler around the fragile arterial branches
 65 LOBAR RESECTIONS 679

Figure 658 A, The right superior pulmonary vein has been divided. Careful dissection exposes the anterior truncus branch of the right
pulmonary artery. This view is achieved by placing the camera through the anterior thoracoscopic port as we then bring the stapling device
through the camera port for division of this pulmonary arterial structure. B, Optimal instrument placement for division of the anterior
truncus branch of the right pulmonary artery. The camera is moved anteriorly, while the vascular stapler is brought through the thoraco-
scopic camera port. An endoleader may be utilized to guide the stapler across these delicate arterial branches. C, The red rubber cath-
eter has been disengaged from the vascular stapler and the stapler is then ready for closure and division. The azygous vein (arrow) lies in
close proximity and must be protected to avoid enclosure within the stapling device. (B, From Nicastri DG, Yun J, Swanson SJ. VATS
lobectomy. In Sugarbaker DS, Bueno R, Zellos L [eds]: Adult Chest Surgery: Concepts and Procedures. New York: McGraw-Hill, Inc.,
2006. Reprinted with permission.)

Once all of the arterial branches are divided, the right

upper lobe bronchus is dissected free by sweeping all
nodal tissue on the bronchus toward the specimen. An
endoscopic stapler is then introduced through the camera
port to divide the bronchus (Fig. 6510). The ssure is
completed with serial rings of the endoscopic stapler and
the specimen is placed in a heavy laparoscopic extraction
sac and removed through the access incision without rib
spreading.

Right Middle Lobectomy

Figure 659 An anterior hilar approach is useful for identifying
and dividing the posterior recurrent arterial branch to the right
upper lobe. Utilizing this method usually obviates the need to
perform tedious ssural dissection for exposure of the interlobar
pulmonary artery. Here, anterior dissection reveals the origin of
the posterior recurrent artery (arrow) to the right upper lobe. This
can then be divided with a vascular stapler brought through the
camera port incision.
(see Fig. 658B and 8C). This division is best accom-
plished with the stapler introduced through the camera
port, with the camera switched to viewing from the access
port.
The next step is to gain access to the recurrent posterior
segmental arterial branch. Thoracoscopically, the most
straightforward and preferred approach is via the anterior
hilum (Fig. 659). This avoids the tedious and often chal-
lenging dissection that can be encountered when exposing
the interlobar pulmonary artery at the conuence of the
horizontal and oblique ssures, especially when the s-
sures are incomplete. If the posterior recurrent branch is
not well visualized from the anterior hilum and the major
ssure is incomplete, one can partially, but carefully, divide
the ssure with a stapler or harmonic scalpel. This provides
better exposure of the interlobar pulmonary artery for
dissection. The goal is to identify the space between the
recurrent ascending arterial branch to the upper lobe and
the superior segmental artery of the lower lobe. This
allows safe division of the recurrent ascending branch and
completion of the posterior ssure.
For right middle lobectomies, the camera port is placed
in the seventh intercostal space in the midaxillary line. This
provides an excellent view of both the anterior hilum and
the major ssure. The anterior access port is usually in the
fth intercostal space, one interspace below the location
utilized for right upper lobectomy. The working port is
usually posterior to the scapular tip in the sixth or seventh
intercostal space. The right middle lobe is retracted later-
ally, and the middle lobe venous drainage is dissected free
and divided using the endovascular stapler. Care must be
taken in dissecting the posterior aspect of the middle lobe
veins off of the underlying pulmonary artery. The middle
lobe bronchus is then exposed. We divide the bronchus
rst because the bronchus is anterior to the middle lobe
artery. One must be careful not to injure the arterial
branches to the middle lobe when dissecting around the
bronchus (Fig. 6511). The arterial branches to the
middle lobe are then isolated and divided with the endo-
vascular stapler. The endoleader technique may be helpful
to guide the stapler around these branches. The ssure is
completed, and the middle lobe is removed in a specimen
sac through the access incision.
Right and Left Lower Lobectomy
The camera port is placed in the eighth interspace in the
posterior axillary line to provide improved exposure to the
posterior hilum and to avoid crowding of the instruments.
The access port is placed anteriorly in the fth intercostal
space. The posterior working port is usually posterior to
the scapular tip in the sixth or seventh interspace. We rst
divide the inferior pulmonary ligament and sample level 9
lymph nodes. The lower lobe is retracted superiorly with
a ring forceps through the posterior port so that the liga-
 680 SECTION XI: THORACIC SURGERY

Retractor

Stapler
Camera

Figure 6510 A and B, The technique to effectively divide the

right upper lobe bronchus. As with division of the anterior truncus
branch of the pulmonary artery, the stapler is brought through the
camera port as the camera is moved to the access incision. Care
must again be taken to avoid injury to the azygous vein (arrow).
(A, From Nicastri DG, Yun J, Swanson SJ. VATS lobectomy. In
Sugarbaker DS, Bueno R, Zellos L [eds]: Adult Chest Surgery:
Concepts and Procedures. New York: McGraw-Hill, Inc., 2006.
B
Reprinted with permission.)

Figure 6511 The middle lobe veins have been divided for this
right middle lobectomy. The right middle lobe bronchus (arrow) lies
anterior to the middle lobe arterial branches. Circumferential
dissection around the bronchus must be performed with care
because the pulmonary artery lies immediately posterior. The
middle lobe arterial branch cannot be seen because it lies just
behind the bronchus.
ment is under tension. A long-tipped electrocautery, or
ultrasonic scalpel, divides the ligament through the access
port. The interlobar pulmonary artery is then isolated
within the ssure. The basilar trunk and the artery to the
superior segment are identied, dissected, and divided
with the endovascular stapler. Usually, the superior seg-
mental artery is divided rst and basilar trunk division
follows. This sequence avoids injury to the superior seg-
mental branch with the stapler used to divide the basilar
arterial branches.
Next, the inferior pulmonary vein is dissected free and
divided with an endovascular stapler. Finally, the bronchus
to the lower lobe is dissected and divided with an endo-
scopic stapler. As in the open technique, care must be
observed on the right side to not impinge on the middle
lobe bronchus. The ssure is completed, and the lobe is
removed in a specimen sac.
Left Upper Lobectomy
In our opinion, the left upper lobectomy is technically the
most difcult because of the variability in the pulmonary
arterial circulation. The order of division of the hilar
structures is the same as with the right upper lobevein,
artery, bronchus. The position of the inferior camera port
is placed more posteriorly to avoid obstruction of the
camera view by the heart and the pericardial fat pad. In
patients with marginal pulmonary function and a small
tumor, a lingula-sparing left upper lobectomy or lingulec-
65 LOBAR RESECTIONS 681
Figure 6512 When isolating and dividing the venous drainage
of the left upper lobe, attention must be focused on mobilizing
the back of the superior venous branches off of the upper lobe
bronchus. The area between the venous branches of the upper
division (thick arrow) and the lingula (thin arrow) is cleared to provide
exposure to the underlying upper lobe bronchus (thick arrow). The
back of the venous tributaries must be cleared from the airway
prior to vascular division.
tomy, as appropriate, should be considered. When isolat-
ing the superior pulmonary vein, care must be taken when
mobilizing it from the anterior aspect of the upper lobe
bronchus. These two structures can be quite adherent to
one another, and precautions should be made to avoid
injury to the back wall of the vein when dissecting this off
of the airway (Fig. 6512).
Isolation and Division of Pulmonary Arterial
and Venous Branches
Vascular Injury
Consequence
A feared complication of lobectomy is an uncontrolled
vascular injury. Scant data is available regarding
division of intrathoracic vessels during pulmonary
resection. Asamura and colleagues24 reported on 842
mechanical vascular divisions in 603 consecutive pul-
monary resections. Endostaplers were used for all appli-
cations except 2. There was an overall stapling failure
rate of 0.1%. One superior pulmonary vein was divided
during a VATS case without the formation of staples.
This hemorrhage was controlled with suture ligation
after conversion to thoracotomy. In this series, reex-
ploration for bleeding complications was never due to
vascular staple line issues.
 682 SECTION XI: THORACIC SURGERY
In the largest series of VATS lobectomies, McKenna and
coworkers11 described their results with 1100 operations.11
There were 9 deaths in this series, for a perioperative
mortality rate of 0.8%. No intraoperative deaths were
encountered. Only 28 cases (2.5%) were converted to a
thoracotomy, and of these, 7 were due to bleeding. No
deaths occurred among these 7 patients. In a separate survey
of 1578 VATS lobectomies, only 1 intraoperative death was
reportedsecondary to a myocardial infarction.25
Grade 2/3/4/5 complication
Repair
A sponge stick or a dental pledget on a clamp should
always be readily available to tamponade bleeding from
stapler malfunction or avulsion of vascular branches. In
thoracoscopic resections, this single maneuver allows
time for adequate control and conversion to an open
thoracotomy, if needed. Minor vascular avulsion
injuries during VATS resections can be adequately
repaired utilizing direct suture repair of the vessel
through the access incision. More signicant injuries,
difculties in exposure, and cases in which patients
exhibit hemodynamic compromise from vascular inju-
ries should be converted to a thoracotomy for effective
vascular control.
Prevention
Having a thorough understanding of the vascular
anatomy is crucial to preventing vascular injury during
pulmonary lobectomy. The relatively thin walls of
pulmonary arterial branches make these structures
more prone to injury than their venous counterparts.
We advocate that pulmonary arterial vessels are never
directly grasped with any instrument. Extra care must
be directed to isolating and dividing these vessels.
During VATS resections, optimization of exposure with
angled thoracoscopes along with correct port place-
ment while adhering to standard thoracic surgical prin-
ciples minimizes the risk of vascular complications.
Lymph Node Dissection
Because the prognosis of lung cancer is directly related to
the presence or absence of lymph node metastases, accu-
rate surgical lymph node staging is paramount. Complete
mediastinal lymph node dissection of levels 2, 4, 7, and 9
is performed on all right-sided lobar resections. Left-sided
mediastinal lymph node dissection is performed on all
lobar resections and should include levels 5, 6, 7, and
9. The American College of Surgery Oncology Group
Z0030 study sought to determine whether long-term
lung cancer survival is effected by mediastinal lymph
node sampling versus complete dissection. This was a
prospective, randomized, multi-institutional study whose
secondary purpose was to ascertain whether perioperative
morbidity or mortality varied between the two groups.
While we await the effects on survival between the two
surgical groups, the studys initial results found no statis-
tically signicant differences in the incidence of chylotho-
rax, recurrent laryngeal nerve injuries, reoperation for
bleeding, or median length of hospital stay between the
two groups.26
Chylothorax
Consequence
Postoperative chylothorax is a rare, but occasionally
morbid, complication after pulmonary resection. The
incidence of pulmonary resections has been reported
from 0.26% to as high as 2.5%.27,28 It is often diagnosed
by the presence of chylous drainage from the chest
tube. Chemical analysis of efuent with elevated tri-
glycerides (>110 mg/dl) conrms the diagnosis. Often,
this complication is self-limited and resolves with dietary
modications, but occasionally, reoperation with tho-
racic duct ligation is required. Patients with chylotho-
rax are prone to infectious complications and may
develop a postoperative empyema.28 Residual intrapleu-
ral chylous collections may be addressed with image-
guided percutaneous drainage techniques.
Grade 2/3/4 complication
Repair
Appreciation of excessive lymphatic leakage intraopera-
tively after lymph node dissection can be addressed
with direct suture or clip ligation. This, however, is not
the usual occurrence, and chylothorax is often diag-
nosed postoperatively with increased chest tube drain-
age. Patients should be started on a medium-chain
triglyceride diet, and if this is not effective, complete
cessation of oral intake should be considered. All
attempts should be taken to minimize residual postop-
erative pleural spaces. These maneuvers are usually suc-
cessful in ameliorating this complication. However,
when drainage exceeds 1 L per day for 7 days, most
surgeons advocate operative exploration with thoracic
duct ligation.29
Prevention
Knowledge of the anatomic course of the thoracic duct
may assist the surgeon in avoiding this potential com-
plication. However, this may not be preventable owing
to the proximity of the duct to the trachea, its often
variable location, and the frequent existence of large
collateral channels among mediastinal lymph nodes.
Intraoperative realization and ligation of signicant
lymphatic injury may prevent chylothoraces from occur-
ring. Careful lymphatic ligation with electrocautery or
ultrasonic shears should minimize postoperative lym-
phatic leaks.
Recurrent Laryngeal Nerve Injury
Consequence
Unilateral recurrent laryngeal nerve dysfunction is
usually well tolerated by most patients, but life-

threatening consequences are possible because patients
are prone to aspiration events. Many patients undergo-
ing pulmonary resections have compromised lung
function owing to longstanding cigarette use. With the
diminished ability to clear pulmonary secretions associ-
ated with vocal cord dysfunction secondary to recurrent
nerve injury, the potential for signicant morbidity
exists. The diagnosis is usually fairly easy to make by
physical examination at the bedside and can be con-
rmed with beroscopy. Watanabe and colleagues30
described their experience with lymph node dissection
for clinical stage I lung cancer and reported on the
incidence of recurrent laryngeal nerve injury. In this
review of 221 VATS resections and 190 open resec-
tions via thoracotomy, there were 5 (2.3%) and 3
(1.6%) recurrent nerve injuries, respectively, in the two
surgical groups. No mention was made regarding the
consequence of this complication in these patients, nor
is this complication expounded further elsewhere in the
literature.
Grade 2/3 complication
Repair
Direct repair is not advised, but several techniques
have been devised to minimize the morbidity associated
with this complication in regards to both improving
voice quality and eliminating aspiration. Early treatment
includes involvement of speech pathologists who can
instruct patients on maneuvers to minimize aspiration
events. Temporary unilateral vocal cord dysfunction
can be remedied by injection of material into the cord
for augmentation purposes.31 Medialization thyroplasty
remains a denitive, yet more invasive, approach toward
managing this complication.32
Prevention
It is important for the surgeon to have a full under-
standing of the anatomy of the recurrent laryngeal
nerves to avoid this complication. During mediastinal
lymph node dissections of levels 5 and 6, care must be
taken to isolate and protect both the vagus and the
phrenic nerves in this region.
REFERENCES
1. Jemal A, Tiwari RC, Murray T, et al. Cancer statistics,
2004. CA Cancer J Clin 2004;528529.
2. Nesbitt JC, Putnam JB, Walsh GL, et al. Survival in early-
stage lung cancer. Ann Thorac Surg 1995;60:466472.
3. Ginsberg R, Rubernstein L. Randomized trial of lobec-
tomy versus limited resection for T1N0 non-small cell
lung cancer. Ann Thorac Surg 1995;60:615623.
4. Landreneau RJ, Sugarbaker DJ, Mack MJ, et al. Wedge
resection versus lobectomy for stage I (T1N0M0) non-
small cell lung cancer. J Thorac Cardiovasc Surg 1997;
113:691700.
5. Warren WH, Faber LP. Segmentectomy versus lobectomy
in patients with stage I pulmonary carcinoma. J Thorac
Cardiovasc Surg 1994;107:10871094.
65 LOBAR RESECTIONS 683
6. Jacobeus HC. Ueber die moglichkeit de zystoskopie bei
untersuchung seroser hohlungen anzuwenden. Munchen
Med Wochenschur 1910;57:20902092.
7. Kirby TJ, Rice TW. Thoracoscopic lobectomy. Ann
Thorac Surg 1993;56:784786.
8. Walker WS, Carnochan FM, Pugh GC. Thoracoscopic
pulmonary lobectomy. Early operative experience and
preliminary clinical results. J Thorac Cardiovasc Surg
1993;106:11111117.
9. Demmy TL, Curtis JJ. Minimally invasive lobectomy
directed toward frail and high-risk patients: a case-control
study. Ann Thorac Surg 1999;68:194200.
10. Nagahiro I, Andou A, Aoe M, et al. Pulmonary function,
postoperative pain, and serum cytokine level after lobec-
tomy: a comparison of VATS and conventional procedure.
Ann Thorac Surg 2001;72:362365.
11. McKenna RJ, Houck W, Fuller CB, et al. Video-assisted
thoracic surgery lobectomy: experience with 1,100 cases.
Ann Thorac Surg 2006;81:421426.
12. Sagawa M, Sato M, Sakurada A, et al. A prospective trial
of systematic nodal dissection for lung cancer by video-
assisted thoracic surgery: can it be perfect? Ann Thorac
Surg 2002;73:900904.
13. Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postopera-
tive pain-related morbidity: video-assisted thoracic surgery
versus thoracotomy. Ann Thorac Surg 1993;56:1285
1289.
14. Swanson SJ, Batirel HF. Video-assisted thoracic surgery
(VATS) resection for lung cancer. Surg Clin North Am
2002;82:541559.
15. Lewis RJ, Caccavale RJ, Bocage JP, et al. Video-assisted
thoracic surgical non-rib spreading simultaneously stapled
lobectomy: a more patient-friendly oncologic resection.
Chest 1999;116:11191124.
16. Benedetti F, Amanzio M, Casadio C, et al. Postoperative
pain and supercial abdominal reexes after posterolateral
thoracotomy. Ann Thorac Surg 1997;64:207210.
17. Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Prevalence
of chronic pain after pulmonary resection by thoracotomy
or video-assisted thoracic surgery. J Thorac Cardiovasc
Surg 1994;107:10791089.
18. Xu WD, Gu YD, Lu JB, et al. Pulmonary function after
complete unilateral phrenic nerve transaction. J Neurosurg
2005;103:464467.
19. Freeman RK, Wozniak TC, Fitzgerald EB. Functional and
physiologic results of video-assisted thoracoscopic dia-
phragm placation in adult patients with unilateral dia-
phragm paralysis. Ann Thorac Surg 2006;81:1853
1857.
20. Higgs SM, Hussain A, Jackson M, et al. Long-term results
of diaphragmatic placation for unilateral diaphragm
paralysis. Eur J Cardiothoacr Surg 2002;21:294297.
21. DiMarco AF, Onders RP, Ignagni A, et al. Phrenic nerve
pacing via intramuscular diaphragm electrodes in tetraple-
gic subjects. Chest 2005;127:671678.
22. Massard G, Wihlm JM. Early complications: esophago-
pleural stula. Chest Surg Clin North Am 1999;9:617
631.
23. Garcia JP, Richards WG, Sugarbaker DJ. Surgical treat-
ment of malignant mesothelioma. In Kaiser L, Kron I,
Spray T (eds): Mastery of Cardiothoracic Surgery.
Philadelphia: Lippincott-Raven, 1997; p 683.
 684 SECTION XI: THORACIC SURGERY
24. Asamura H, Suzuki K, Kondo H, et al. Mechanical
vascular division in lung resection. Eur J Cardiothorac
Surg 2002;21:879882.
25. Mackinlay TA. VATS lobectomy: an international survey.
Presented at the IVth International Symposium on
Thoracoscopy and Video-Assisted Thoracic Surgery, May
1997, Sao Paulo, Brazil.
26. Allen MS, Darling GE, Pechet TT, et al. Morbidity and
mortality of major pulmonary resections in patients with
early-stage lung cancer: initial results of the randomized,
prospective ACOSOG Z0030 trial. Ann Thorac Surg
2006;81:10131020.
27. Cerfolio RJ, Allen MS, Deschamps C, et al. Postoperative
chylothorax. J Thorac Cardiovasc Surg 1996;112:1361
1365.
28. Schimizu K, Yoshida J, Nishimura M, et al. Treatment
strategy for chylothorax after pulmonary resection and
lymph node dissection for lung cancer. J Thorac Cardio-
vasc Surg 2002;124:499502.
29. Patterson GA, Todd TR, Delarue NC, et al. Supradia-
phragmatic ligation of the thoracic duct in intractable
chylous stula. Ann Thorac Surg 1981;32:4449.
30. Watanabe A, Koyanagi T, Obama T, et al. Assessment of
node dissection for clinical stage I primary lung cancer
by VATS. Eur J Cardiothorac Surg 2005;27:745
752.
31. Hartl DM, Travagli JP, Leboulleux S, et al. Clinical
review: concepts in the management of unilateral
recurrent laryngeal nerve injury after thyroid surgery.
J Clin Endocrinol Metab 2005;90:30843088.
32. Bielamowicz S. Perspectives on medialization laryngo-
plasty. Otolaryngol Clin North Am 2004;31:139
160.
66
Bronchial and Vascular
Sleeve Lobectomy
M. Blair Marshall, MD and Fabio May da Silva, MD
INTRODUCTION
Bronchial and vascular sleeve resections have come to
replace pneumonectomy in the management of central
disease of the airway and pulmonary artery (PA). Sleeve
resection is performed in approximately 5% of patients
undergoing resection for lung cancer.1 Although this
technique was initially reserved for patients with inade-
quate pulmonary reserve, it is now considered the optimal
technique in all patients, regardless of pulmonary status.
Bronchial sleeve resection was introduced by Price
Thomas in 1947 at the Brompton Hospital in London.
In this case, sleeve lobectomy was carried out for a carci-
noid tumor located in the right main bronchus.2 Follow-
ing this, bronchial sleeve resection became the standard
procedure for benign lesions of the central airway. In lung
cancer patients, much of the credit for popularizing bron-
chial sleeve resection as an alternative to pneumonectomy
has to be given to Paulson and coworkers.3,4 Initial reports
of postoperative morbidity and mortality prohibited
routine use of sleeve resection in patients with adequate
pulmonary reserve. However, the increased morbidity in
patients undergoing sleeve resection reected the decreased
pulmonary reserve, which required a sleeve resection in
these early reports of sleeve lobectomy.5
Sleeve resection may be appropriate with any lobectomy
but is most frequently performed in a right upper lobec-
tomy (Fig. 661). Combined bronchovascular sleeve
resections are most common on the left owing to the
position of the PA (Fig. 662). Again, the most com-
monly performed sleeve resection on the left is the upper
lobe.
Bronchial and bronchovascular sleeve resections are
complex, technically demanding procedures. Operative
mortality ranges from 0% to 6.2%,6,7 with postoperative
morbidity ranging from 10% to 50%.8,9 Some data dem-
onstrate that the perioperative risks of bronchial and
bronchovascular sleeve resection are comparable with
those of standard lobectomy.1,1012 Although concerns
have been raised over the adequacy of oncologic clearance
with this technique, the literature demonstrates equivalent
local recurrence and long-term survival in patients under-
going sleeve resection compared with those receiving
pneumonectomy.1315 The advantages of sleeve resection
have been clearly demonstrated. As the preoperative
management strategy of patients with advanced lung
cancer has shifted over the past two decades, additional
data demonstrate that bronchial and bronchovascular
sleeve resection may be performed safely after neoadjuvant
therapy.13
Factors affecting survival include the presence of nodal
disease, the type of bronchoplastic procedure, impaired
lung function, and the presence of cardiovascular risk.16,17
An additional important consideration is the postoperative
quality of life in patients who undergo pneumonectomy
compared with sleeve lobectomy. Pneumonectomy, a
disease, is associated with long-term sequelae of pulmo-
nary hypertension and respiratory failure. Also, one must
not forget that patients may go on to develop a second
primary tumor.
INDICATIONS
Tumors with involvement of lobar bronchus preclud-
ing lobectomy, but not inltrating so far as to require
pneumonectomy (Fig. 663)
Patients with compromised pulmonary reserve who
cannot tolerate pneumonectomy
N1 Nodal disease with involvement of lobar bronchus
and/or PA
Metastatic malignancies with lobar extension to main
bronchus
Major bronchial disruption as result of penetrating
or blunt chest trauma requiring dbridement and
reapproximation
Benign bronchial stricture related to trauma or inam-
matory disease
OPERATIVE STEPS
Step 1 Bronchoscopy to evaluate extent of disease
within airway by operating surgeon (Fig. 664)
 686 SECTION XI: THORACIC SURGERY

Figure 661 Tumor involving the right upper lobe bronchus with lines of transection demonstrate an adequate resection margin on the
proximal and distal bronchus with reanastomosis.

Figure 662 Bronchial and vascular sleeve lobectomy specimen

demonstrates the proximity of the left upper lobe bronchus and
left pulmonary artery. Figure 664 Bronchoscopic image demonstrates a right upper
lobe tumor extending into the right main stem orice.

Figure 663 Computed tomography (CT) images of a left upper lobe tumor that would suggest a potential for sleeve lobectomy.
 66 BRONCHIAL AND VASCULAR SLEEVE LOBECTOMY 687

Figure 665 Intraoperative photograph of the tumor in Figure Figure 666 Intraoperative photograph of a right upper lobe
664 with the proximal right main stem divided and stay sutures sleeve resection with both the proximal and the distal airways
on the proximal and distal airway. divided. Forceps are holding the lobectomy specimen.

Step 2 General anesthesia with double-lumen tube

placed in bronchus opposite planned side of
resection
Step 3 Lateral decubitus position
Step 4 Thoracotomy (posterolateral and anterior
approaches both adequate)
Step 5 Thoracic exploration (visual and manual)
Step 6 Assess resectability prior to irreversible
maneuvers
Step 7 Mediastinal lymphadenectomy
Step 8 Obtain proximal and distal control of PA, ligate
and divide vein to lobe being resected
Step 9 Venous control if unable to get distal control
of PA Figure 667 Bronchial anastomosis being performed with the
Step 10 Circumferential dissection of main stem and interrupted suture technique.
distal bronchus. Place umbilical tapes to facili-
tate division
Step 11 Complete ssures around disease when Step 22 Fiberoptic bronchoscopy
possible Step 23 Extubate patient in operating room
Step 12 Stay sutures on proximal and distal airway to
orient anastomosis
Bronchoscopy
Step 13 Harvest pericardium for vascular repair when
needed The foundation of bronchial evaluation is bronchoscopy.
Step 14 Notify anesthesiologist when preparing for resec- This denes the extent of pathology in the bronchus.
tion and clamping PA Rigid or exible bronchoscopes can be used, although
Step 15 Heparin 30 units/kg intravenously when plan- we routinely use exible bronchoscopy. It is important
ning on vascular sleeve resection prior to clamp- that the operating surgeons perform the examination.
ing main PA Pertinent ndings indicating a probable sleeve resection
Step 16 Divide proximal airway and artery once vessels include endobronchial tumor, submucosal vascularity, and
have been controlled (stay sutures) (Fig. 665) thickening. Careful evaluation of bronchial motion is
Step 17 Frozen section margins (Fig. 666) important to infer the state of tissues outside the bron-
Step 18 Bronchial anastomosis (Fig. 667) chus. It may be difcult to determine a need for pulmo-
Step 19 Vascular anastomosis or patch angioplasty nary arterial reconstruction preoperatively; however, one
Step 20 Wrap bronchial anastomosis with viable ap should always be prepared, especially with central tumors
Step 21 Closure or N1 disease. If there is a question about the extent of
 688 SECTION XI: THORACIC SURGERY
disease, multiple biopsies may be performed at the time
of bronchoscopy.
Sleeve lobectomy can be planned, but the surgeon must
also prepare the patient and family for the possibility that
a pneumonectomy may be required because of technical
issues or tumor extension
Complications of bronchoscopy are discussed in Section
XI, Chapter 64.
Double-Lumen Tube Placement
Misplacement of the double-lumen tube can lead to
hypoxia and hypoventilation. Preoperative bronchoscopy
ensures appropriate positioning, although the tube can
become dislodged during the procedure when manipulat-
ing the airway. The endobronchial tube should be placed
in the bronchus opposite the side of resection.
Intraoperative Displacement (Fig. 668)
Consequence
Hypoxia and hypoventilation during single lung
ventilation.
Grade 15 complication
Repair
Bronchoscopy is used to check the position of the
bronchial cuff and to ensure that the orice of the
bronchial or tracheal lumen is neither pressed against
the bronchial or tracheal walls nor blocking the orice
to the left upper lobe. For right-side tubes, the position
of the slit in the bronchial cuff with respect to the orice
to the right upper lobe must be rechecked, as well as
the patency of the right middle and lower lobes.
During the dissection or once the airway has been
divided, the double-lumen tube can herniate out of its
appropriate position and result in occlusion of the bron-
Figure 668 Double-lumen tube correctly positioned in the
airway initially, followed by mechanism for hypoxia when the double-
lumen tube moves proximally and the balloon herniates, preventing
the nonoperative lung from being adequately ventilated.
chus to the ventilated lung. Usually, one may simply
inate the operative lung in order to ventilate while the
problem is identied and resolved. If, however, the airway
has already been divided, this may not be possible. Dea-
tion of the bronchial balloon eliminates the occlusion and
allows the patient to be ventilated while the problem is
investigated.
Prevention
During the operation, one must be aware of the pulse
oximetry in order to intervene early if there has been a
change in the ability of the patient to be ventilated.
Exposure
Complications associated with the various exposures are
covered in Section XI, Chapter 64.
Dissection of the Hilum
Vascular Injury
Consequence
Bleeding that occurs as a result of PA injury ranges
from minimal, which is controlled and resolved with
direct pressure, to excessive and life-threatening; the
latter is rare.
Grade 15 complication
Repair
If injury to the vessel occurs, the bleeding should be
controlled initially by direct pressure with a folded
gauze sponge, specically guarding against any maneu-
ver that might further tear the vessel. Adequate expo-
sure is obtained and both proximal and, when possible,
distal control of the artery is obtained. The artery may
be clamped without heparinization for short periods. If
distal control cannot be obtained, control of the pul-
monary veins is helpful to minimize blood loss during
repair of large injuries or later during arterioplasty if
necessary. Primary repair is usually all that is necessary.
Vascular clamps may be applied to the area of injury
when feasible with subsequent direct repair, although
one should be careful when using this technique. When
a tear in the artery extends proximally, cardiopulmo-
nary bypass may be required for repair.
Prevention
One must be cautious when working with central
tumors. Excessive traction on the mass, especially with
left upper lobe tumors or bulky N1 disease, can result
in arterial disruption. It is important to routinely obtain
proximal control of the main PA trunk as well as the
pulmonary veins prior to proceeding with the central
dissection or resection to avoid devastating conse-
quences. Because the veins are located more anterior,
they are not commonly involved when performing a
sleeve resection.
 66 BRONCHIAL AND VASCULAR SLEEVE LOBECTOMY
Bronchial Anastomosis
Anastomotic Torsion or Kinking
Consequence
Failure to orient the bronchial anastomosis properly
can result in kinking of the airway or torsion. This is
usually identied during the postoperative bronchos-
copy and can be directly repaired by taking down the
anastomosis. Retained secretions and pneumonia are
suggestive of this in the postoperative setting.
Grade 3/4 complication
Repair
When mild, retained secretions can be managed with
aggressive pulmonary toilet and repeat therapeutic
bronchoscopy. Stenting of the anastomosis can be
effective in the management of luminal compromise.
For those refractory to conservative techniques, reop-
eration is necessary with either revision of the anasto-
mosis or completion pneumonectomy.
Prevention
Placing stay sutures prior to division of the airway helps
to maintain proper orientation to prevent torsion.
Liberal use of beroptic bronchoscopy and minitrache-
ostomy in the postoperative setting aids in pulmonary
toilet.
Leak/Dehiscence/Bronchovascular Fistula
Circumferential dissection of the bronchus is performed
prior to division of the airway when performing the resec-
tion. In performing a lymphadenectomy, much of the
blood supply to the bronchus is compromised. This places
the anastomosis at risk for complications.
Consequence
Although small air leaks may heal spontaneously, one
should never leave the operating room with a leak
from the bronchial anastomosis. Persistent postopera-
tive air leaks, new air leaks, postoperative fever, or an
elevated white blood cell count should alert one to the
possibility of an anastomotic complication. Flexible
bronchoscopy should be done to assess the bronchial
anastomosis. In this setting, the morbidity can range
from minimal, with the development of fever and leu-
kocytosis, to empyema or bronchovascular stula. The
latter is rarely salvageable.
Grade 25 complication
Repair
One should have a very low threshold for beroptic
bronchoscopy during the postoperative period. Most
thoracic surgeons advocate the routine use of bron-
choscopy prior to discharge.1,10 A small persistent leak
may be managed conservatively if clinically indicated,
with some authors reporting the success of brin glue
in this setting.12 Dehiscence requires a more aggressive
689
approach with reoperation and repair of the bronchus,
if viable, or completion pneumonectomy. One should
remain clinically suspicious and intervene early because
infections from bronchial dehiscence are associated
with complications ranging from empyema and bron-
chopleural stula to bronchovascular stula, usually a
fatal event. Anastomotic strictures occur late and can
usually be managed with bronchoscopic interventions
including dilation and stenting.
Prevention
When mobilizing the airway, the operating surgeon
must pay close attention to the dissection of the bron-
chus itself and the corresponding bronchial vessels.
Excessive dissection or failure to maintain an adequate
blood supply to the airway may result in poor healing
with dehiscence or stricture formation.18,19
The bronchial anastomosis may be performed in an
interrupted, continuous, or combined fashion with no
particular technique demonstrating superiority. When
there is a size discrepancy between the proximal and the
distal bronchi, an interrupted technique may allow for
better approximation. If the size discrepancy is excessive,
telescoping of the distal bronchus into the proximal, as
with a lung transplant anastomosis, can be performed
(Fig. 669).20 Stay sutures placed during the time of dis-
section may be tied together to help alleviate tension on
the anastomosis. Division of the inferior pulmonary liga-
ment will relieve some tension, but if not completely
successful, a pericardial release will allow for greater mobi-
lization of the lower lobe.
The anastomosis should be tested at the time of the
initial operation, and any air leaks should be primarily
repaired. A ap of well-vascularized tissue should be used
to wrap the anastomosis21 and, in particular, to separate
the bronchial anastomosis from the PA. Most commonly,
intercostal muscle, pleura, or pericardial fat is used. For
the intercostal muscle, one must be careful not to wrap
the bronchus circumferentially because ossication of the
muscle with bronchial stricture may result.22 At the com-
pletion of the operation, prior to extubation, beroptic
bronchoscopy should be performed to ensure that there
is no luminal compromise or torsion.
Atelectasis
Consequence
Persistent atelectasis is one of the most common mor-
bidities reported after bronchoplasty. It may be due to
the interruption of the ciliary epithelium and lymphat-
ics or to anastomotic edema.
Grade 2 complication
Repair
Aggressive pulmonary toilet during the postoperative
period is usually effective. However, if it is due to anas-
tomotic compromise related to technical issues, these
should be addressed as previously discussed.
 690 SECTION XI: THORACIC SURGERY

Figure 669 The intussusception technique for

the bronchial anastomosis when size discrepancy is
an issue.

Prevention
Anastomotic edema will resolve on its own, although
some authors advocate the use of perioperative
steroids.13

Pedicled Flaps
Devascularization of the Flap
Consequence
If the vascular supply is not protected, the ap will be
nonviable and can contribute to postoperative anasto-
motic complications.
Grade 2/3 complication
Repair
Poor blood supply to the ap can be identied in the
operating room. If this occurs, another ap should be
used as an alternative.
Prevention Figure 6610 Intraoperative photograph demonstrates a peri-
If planning on an intercostal ap, it should be harvested cardial patch arterioplasty on the left main pulmonary artery.
prior to placing the retractor against the ribs, thus
avoiding trauma to the ap. For pericardial aps, the an elevated white blood cell count. One must have a
dissection is begun at the base of the pericardium and high index of suspicion in any patient with a fever or
the chest wall. As the ap is mobilized cephalad, one elevated white blood cell count following vascular
must be constantly conscious of the vascular supply to tangential or sleeve resection. Oligemia may suggest
the pedicle. As the pedicle thins out, it is possible to this on the postoperative chest lm. The diagnosis
inadvertently divide the vascular pedicle. is usually made with a perfusion scan or pulmonary
arteriogram.
Grade 3/4 complication
PA Reconstruction
Repair
PA Thrombosis
If a compromise in the lumen of the artery is identied
Consequence at the initial operation, the anastomosis may be revised
When PA thrombosis occurs, the remaining lobe necro- by either converting a tangential resection with recon-
ses. This results in infectious symptoms with fever and struction to a circumferential resection with end-to-end
 66 BRONCHIAL AND VASCULAR SLEEVE LOBECTOMY
A ASSOCIATED WITH
B after sleeve lobectomy or bronchoplasty for bronchial
Figure 6611 Intraoperative photographs demonstrate the tech-
nique for an end-to-end pulmonary artery sleeve resection. A, Both
the proximal and the distal pulmonary arteries are clamped. B, The
completed anastomosis.
anastomosis or revision of the primary anastomosis. If
a sleeve resection of the artery was performed without
need for a bronchial sleeve, the distal artery may not
be able to be directly reconstructed to the proximal
artery. In this setting, a tube graft can be fashioned
from pericardium.23 Some authors advocate a sleeve
resection of the bronchus to shorten the main stem and
allow for the arterial ends to come together.24
Prevention
Pulmonary arterial thrombosis occurs as a result of
technical failure. Either the repair is too narrow or the
artery is under torsion or kinked. When performing a
tangential resection, if the resection exceeds over 25%
of the arterial circumference, a patch angioplasty should
be performed (Fig. 6610).25 When more of the arterial
691
circumference is involved, a circumferential resection
with an end-to-end anastomosis may be preferable
(Fig. 6611). Torsion or kinking can occur when the
arterial anastomosis is performed before the bronchial
anastomosis. One must pay careful attention to the
course of the artery once the lobe is reexpanded to
identify this before leaving the operating room.
Lymphadenectomy
It is preferable to accomplish the lymphadenectomy prior
to the bronchial sleeve procedure to avoid traction on or
manipulation of the anastomosis.
POSTOPERATIVE COMPLICATIONS
PULMONARY SURGERY
Bleeding
Pneumonia
Atelectasis
Atrial brillation
Esophageal injury
Chyle leak
Phrenic nerve injury
Recurrent nerve injury
Post-thoracotomy pain syndrome
REFERENCES
1. Suen HC, Myers BF, Guthrie T, et al. Favorable results
malignancies. Ann Thor Surg 1999;67:15571562.
2. Thomas CP. Conservative resection of the bronchial tree.
J R Coll Surg Edinb 1955;1:169186.
3. Paulson DL, Shaw RR. Preservation of lung tissue by
means of bronchoplastic procedures. Am J Surg 1955;89:
347355.
4. Paulson DL, Urschel HC, McNamara JJ, Shaw RR.
Bronchoplastic procedures for bronchogenic carcinoma.
J Thorac Cardiovasc Surg 1970;59:3847.
5. Faber LP, Jensik RJ, Kittle CF. Results of sleeve lobec-
tomy for bronchogenic carcinoma in 101 patients. Ann
Thorac Surg 1984;37:279285.
6. Okada M, Yamagishi H, Satake S, et al. Survival related to
lymph node involvement in lung cancer after sleeve
lobectomy compared with pneumonectomy. J Thorac
Cardiovasc Surg 2000;119(4 pt 1):814819.
7. Hollaus PH, Wilng G, Wurnig PN, Pridun NS. Risk
factors for the development of postoperative complications
after bronchial sleeve resection for malignancy: a univariate
and multivariate analysis. Ann Thorac Surg 2003;75:966
972.
8. Mezzetti M, Panigalli T, Giuliani L, et al. Personal
experience in lung cancer sleeve lobectomy and sleeve
pneumonectomy. Ann Thorac Surg 2002;73:17361739.
 692 SECTION XI: THORACIC SURGERY
9. Icard P, Regnard JF, Guibert L, et al. Survival and
prognostic factors in patients undergoing parenchymal
saving bronchoplastic operation for primary lung cancer: a
series of 110 consecutive cases. Eur J Cardiothorac Surg
1999;15:426432.
10. Ludwig C, Stoelben E, Olschewski M, Hasse J. Compari-
son of morbidity, 30-day mortality, and long-term survival
after pneumonectomy and sleeve lobectomy for nonsmall
cell lung carcinoma. Ann Thorac Surg 2005;79:968973.
11. Yoshino I, Yokoyama H, Yano T, et al. Comparison of
surgical results of lobectomy with bronchoplasty and
pneumonectomy for lung cancer. J Surg Oncol 1997;64:
3235.
12. Lausberg HF, Graeter TP, Tscholl D, et al. Bronchovas-
cular versus bronchial sleeve resection for central lung
tumors. Ann Thorac Surg 2005;79:11471152.
13. Redina E, Venuta F, Giacomo T, et al. Safety and efcacy
of bronchovascular reconstruction after induction chemo-
therapy for lung cancer. J Thorac Cardiovasc Surg 1997;
114:830837.
14. Tronc F, Grgoire J, Rouleau J, Deslauriers J. Long-term
results of sleeve lobectomy for lung cancer. Eur J Cardio-
thorac Surg 2000;17:550556.
15. Deslauriers J, Gregoire J, Jacques LF, et al. Sleeve
lobectomy versus pneumonectomy for lung cancer: a
comparative analysis of survival and sites of recurrences.
Ann Thorac Surg 2004;77:11521156.
16. Fadel E, Yildizeli B, Chapelier AR, et al. Sleeve lobectomy
for bronchogenic cancers: factors affecting survival. Ann
Thorac Surg 2002;74:851858.
17. End A, Hollaus P, Pentsch A, et al. Bronchoplastic
procedures in malignant and nonmalignant disease:
multivariable analysis of 144 cases. J Thorac Cardiovasc
Surg 2000;120:119127.
18. Vildizeli B, Fadel E, Mussot S, et al. Morbidity, mortality
and long-term survival after sleeve lobectomy for non-
small cell lung cancer. Eur J Cardiothorac Surg 2007;31:
95102.
19. Kutlu CA, Goldstraw P. Tracheobronchial sleeve resection
with the use of a continuous anastomosis: results of one
hundred consecutive cases. J Thorac Cardiovasc Surg
1999;117:11121117.
20. Teddler M, Anstadt MP, Teddler SD, Lowe JE. Current
morbidity and mortality after bronchoplastic procedures
for malignancy. Ann Thorac Surg 1992;54:387391.
21. Hollaus PH, Janakiev D, Pridun NS. Telescope anastomo-
sis in bronchial sleeve resections with high-caliber mis-
match. Ann Thorac Surg 2001;72:357361.
22. Turrentine MW, Kesler KA, Wright CD, et al. Effect of
omental, intercostal, and internal mammary artery pedicle
wraps on bronchial healing. Ann Thorac Surg 1990;49:
574578.
23. Deeb ME, Sterman DH, Shrager JB, Kaiser LR. Bronchial
anastomotic stricture caused by ossication of an intercos-
tal muscle ap. Ann Thorac Surg 2001;71:1700
1702.
24. Rendina EA, Venuta F, De Giacomo T, et al. Sleeve
resection and prosthetic reconstruction of the pulmonary
artery for lung cancer. Ann Thorac Surg 1999;68:995
1001.
25. Dartevalle P. How I do it: sleeve lobectomy. General
Thoracic Symposium at Annual Meeting, American
Association for Thoracic Surgery. Accessible at www.
conferencearchives.com/aats2006/index.html
26. Shrager JB, Lambright ES, McGrath CM, et al. Lobec-
tomy with tangential pulmonary artery resection without
regard to pulmonary function. Ann Thorac Surg 2000;70:
234239.
67
Pneumonectomy
James E. Davies, MD and Mark S. Allen, MD

INTRODUCTION INDICATIONS

The rst successful pneumonectomy was performed by Carcinoma of lung (centrally located)
Rudolph Nissen in 1931 in Berlin, Germany. His patient Inammatory/infectious lung disease with destroyed
was a 12-year-old girl with severe bronchiectasis of the lung
entire left lung. This was a staged procedure with a Proximal bronchial stricture/obstruction with
cervical phrenic crush performed initially, followed by a destroyed lung
left thoracotomy. The pneumonectomy was performed Completion pneumonectomy
by placing a rubber tube ligature around the hilum of Extrapleural pneumonectomy for malignant
the left lung. The chest was packed, and 2 weeks later, mesothelioma
the lung sloughed off. A small bronchial stula devel- Trauma
oped but closed spontaneously 2 months later.1 On
April 5, 1933, Everts Graham,2 Chair of Surgery at
Washington School of Medicine, performed the rst OPERATIVE STEPS
successful single-stage pneumonectomy. The patient was
a 48-year-old gynecologist with a squamous cell carci- Step 1 Anesthesia (double-lumen endotracheal tube
noma of the left lung that could be removed only with and epidural catheter)
a pneumonectomy. Step 2 Posterolateral thoracotomy
Since these early reports, the number of pneumonecto- Step 3 Exploration of pleural cavity
mies has steadily increased and mortality rates have Step 4 Mediastinal lymphadenectomy
improved. These improvements are probably secondary to Step 5 Mobilization of pulmonary hilum
a combination of better surgical approaches, patient selec- Step 6 Ligation of pulmonary veins
tion, anesthesia, and postoperative care. Wilkins and Step 7 Ligation of pulmonary artery
coworkers3 showed a decrease in operative mortality, from Step 8 Transection of bronchus
56% to 11%, over a period of 4 decades (19311970) at Step 9 Closure
the Massachusetts General Hospital. Numerous reports
since 1980 have shown mortality rates from 3% to 12%.36
Mediastinal Lymphadenectomy
Certain risk factors associated with higher mortality rates
have been identied. Right-sided pneumonectomies have Chylothorax
a higher morbidity and mortality than left-sided pneumo- Chylothorax is a rare complication after pneumonectomy.
nectomies. Reports by Nagasaki and associates4 and Wahi In 1993, Vallieres and associates15 published a review of
and colleagues5 conrmed signicantly higher mortality the literature that showed a total of only 27 cases. Since
rates with right- versus left-sided pneumonectomies. Wahi that time, other series have shown an incidence of 0.37%
and colleagues reported in 19895 that right-sided pneu- to 0.5% of pneumonectomies.16,17 Cerfolio and colleagues17
monectomy had a 12% mortality versus only 1% with left reviewed the Mayo Clinic experience from 1987 to 1995
pneumonectomy. In 2001, Martin and coworkers,7 from (315 patients) and found an incidence of 0.37%.
Memorial Sloan-Kettering Cancer Center, reported a 24%
mortality for right-sided pneumonectomy versus 2.4% for Consequence
left-sided pneumonectomy. Other risk factors shown to Initially, chylothorax is difcult to diagnose in the
be associated with higher mortality include age greater pneumonectomy patient because normally all chest
than 70 years, neoadjuvant therapy, completion pneumo- tubes are removed within 24 hours. This leads to a
nectomy, and resection for inammatory or infectious delay in the diagnosis and a potentially extended hos-
disease.814 pital stay. The diagnosis should be suspected when
 694 SECTION XI: THORACIC SURGERY

there is rapid accumulation of uid within the pleural Left jugular

vein
cavity. In the series by Sarsam and coworkers,16 nine
patients had a rapid accumulation of uid but only
four were symptomatic. These symptoms are normally
increased respiratory difculty or compromise. Tension
chylothorax requiring emergency drainage was described
by Karwande and associates in 1986.18
Chylothorax can lead to serious metabolic defects sec-
ondary to the composition of chyle. The loss of protein,
Superior vena
fat, and fat-soluble vitamins requires increased nutritional cava
support, and the immunologic status of the patient can
be affected by the loss of chyle.
Grade 2/3 complication
Repair
The initial treatment for a chylothorax is conserva- Thoracic duct
tive management with external drainage, nutritional Aorta
support, and observation. The diagnosis is suggested
by the presence of milky white drainage and conrmed
by an elevated triglyceride level of the uid (>110 mg/
Azygos vein
dl). The patient should be placed on total parental
nutrition or a medium-chain triglyceride diet, and the
volume of the uid should be observed and recorded
accurately. If it is greater than 500 ml/day, it is less
likely to resolve with conservative therapy and surgical
intervention should be performed. The leak can be
Diaphragm
isolated by giving 100 to 200 ml of olive oil or cream
to the patient by nasogastric tube 2 to 3 hours prior to
the surgical exploration.19 This will increase the output
of the milky uid from the duct and make it easier to
identify intraoperatively. The chest should be reopened
on the side of the pneumonectomy and the thoracic Cisterna chyli
duct ligated. This can be done by direct closure on the
leak, mass ligation of the ductal tissue, or supradia-
phragmatic ligation of the duct on the right side. Other
techniques that have been described include pleuro-
peritoneal shunting with double-valve Denver perito-
neal shunts and the use of brin glue.20,21
Prevention Figure 671 Anatomy of the thoracic duct.
The best way to prevent an injury to the thoracic duct
during a pneumonectomy or any thoracic procedure is logic resection) or unintentional (secondary to traction or
through knowledge of the anatomy of the duct (Fig. direct injury). Mediastinal lymphadenectomy can lead to
671). It originates from the cisterna chyli at the level more injuries, especially on the left. Bollen and colleagues23
of the second lumbar vertebrae and ascends through reported that 3 out of 62 patients undergoing complete
the aortic hiatus into the chest. The duct continues mediastinal lymphadenectomy suffered unintentional
superiorly on the anterior surface of the vertebral injury. Conversely, in the American College of Surgical
column behind the esophagus and between the aorta Oncology Groups (ACOSOG) study24 of lymphadenec-
and the azygos vein. At the level of T4 or T5, it crosses tomy versus lymph node sampling, no increase was
the midline behind the aorta into the left side of the observed in the incidence of recurrent nerve injuries with
chest. The duct continues superiorly adjacent to the mediastinal lymph node dissection.
esophagus and drains into the left subclavianjugular
junction.22 Consequence
Injury to recurrent laryngeal nerve leads to unilateral
Recurrent Laryngeal Nerve Injuries vocal cord paralysis. The degree of dysfunction is vari-
Recurrent laryngeal nerve injuries are not common with able, but it may cause inadequate cough, inability to
pneumonectomy or any pulmonary resection. They can clear secretions, or aspiration in the postoperative
be intentional (sacricing the nerve for a complete onco- setting. Patient age, recent weight loss, and overall

3p
3a
Vagus nerve
6 Therefore, the work-up tends to be directed at ruling out
5
Phrenic nerve
Figure 672 Anatomy of the left aortopulmonary window with
levels V and VI lymph nodes.
pulmonary function prior to resection correlate with
the patients ability to compensate postoperatively.
Grade 3 complication
Repair
The treatment and timing for recurrent laryngeal nerve
injuries depend on the status and condition of the
patient. Denitive treatment is with medialization of
the vocal cords, normally performed by an otolaryn-
gologist. Three techniques described include vocal
cord injection, neuromuscular transfer, and vocal cord
implant.25
Prevention
Injury to the recurrent laryngeal nerve is most common
on the left during resection of stations 5 and 6 lymph
nodes. Care must be taken during this portion of the
procedure to avoid direct injury or excessive traction
on the recurrent laryngeal nerve. If needed, sharp dis-
section rather than cautery should be used. A vessel
loop can also be placed around the nerve for gentle
traction. This decreases the crushing effect of picking
up the nerve directly. Figure 672 shows the anatomy
of the nerve in relation to levels V and VI lymph
nodes.
Mobilization of the Pulmonary Hilum
Esophagopleural Fistula
Esophagopleural stula (EPF) occurs in 0.5% to 0.65% of
patients undergoing pneumonectomy.2628 EPFs are more
67 PNEUMONECTOMY 695
common of the right side, and the incidence is increased
in patients undergoing pneumonectomy for inammatory
or infectious diseases. This is most likely secondary to the
difculty in the dissection of the pulmonary hilum in these
patients. Massard and Wihlm29 divided EPFs into two
groups: early and late (>3 mo). The etiology in the early
group was direct operative trauma or devascularization/
necrosis versus recurrent cancer or chronic infectious/
inammatory disorder in the late group. The diagnosis can
be difcult to make in either group because EPFs tend to
present in the same way as a bronchopleural stula (BPF).
a BPF with a exible bronchoscopy. If this is negative, a
water-soluble swallow study should be performed imme-
diately to rule out an EPF.
Consequence
EPF presents with an associated empyema in both the
early and the late groups. Early reports cited a mortal-
ity of 50% in these patients.28,30 More recent reports,
including one from the Mayo Clinic by Deschamps and
coworkers in 2001,31 showed a mortality of approxi-
mately 7.5% in patients with empyemas after pneumo-
nectomy. The increased mortality depends on the
etiology of the stula; the late group has a higher inci-
dence of recurrent malignancy.
Grade 3 complication
Repair
The initial treatment of empyema with EPF is drainage
of the empyema, appropriate antibiotics, and nutri-
tional support with nasogastric tube or parenteral nutri-
tion. Denitive treatment depends on the etiology of
the stula, but EPF is treated in the same way as a BPF,
which is discussed in detail later in this section.
Prevention
If a difcult dissection of the mediastinum is suspected
or found during the operation, a large bougie may be
inserted to aid in identifying the esophagus. This may
help avoid but will not prevent direct injury to the
esophagus. If an injury is suspected, methylene blue or
air may be injected into the nasogastric tube to help
identify the injury. Once the injury is located, it can be
closed in two layers of ne nonabsorbable suture and
buttressed with a pleural ap or other viable tissue.30
Cardiac Herniation
Cardiac herniation or torsion is a rare complication after
pneumonectomy, but it is associated with a mortality rate
of 40% to 50%.32,33 It is associated with opening the peri-
cardial sac for intrapericardial pneumonectomy. On the
left, herniation results in strangulation of the left ventricle
with decreased lling and ejection. There is also decreased
or no coronary blood ow, leading to myocardial isch-
emia. The right-sided herniation leads to a counterclock-
wise rotation of the heart and obstruction of the superior
and inferior vena cava (Fig. 673). These normally present
 696 SECTION XI: THORACIC SURGERY
Figure 673 Chest radiograph of right-sided cardiac herniation.
within 24 hours but have been reported up to 72 hours
postoperatively.
Consequence
The patient will develop abrupt hypotension, tachycar-
dia, increased venous pressure, and progressive cardio-
vascular collapse. If the diagnosis and treatment are not
instituted immediately, fatality will result.32,33
Grade 3/5 complication
Repair
After diagnosis, the patient should be placed immedi-
ately with the operative side up and taken back to the
operating room. Upon reopening of the thoracotomy,
the cardiac herniation should be reduced and the peri-
cardium reconstructed, usually with a synthetic patch.
Prevention
Closure of all but very small pericardial defects should
be performed intraoperatively. If the pericardium
cannot be closed without causing cardiac restriction,
a synthetic patch should be used. This does not fully
eliminate postoperative herniation, as reported by
Veronesi and associates in 2001.34 Also, the pleural
cavity should not be placed or kept on excessive suction.
Figure 674 shows a large pericardial defect after a left
extrapleural pneumonectomy.
Figure 674 Intraoperative large pericardial defect after intra-
pericardial pneumonectomy.
Ligation of the Pulmonary Veins
Peripheral Tumor Embolus
Consequence
Peripheral tumor embolus during a pneumonectomy is
a rare but potentially lethal complication.35 It was rst
described by Taber36 and Senderoff and Kirschner37 in
the early 1960s. Whyte and colleagues38 reported that
the distribution of the emboli were most commonly
major arterial sites: the aortic bifurcation and femoral
arteries (50%), the carotid and cerebral arteries (32%),
and the visceral arteries (18%).
Grade 3/4 complication
Repair
If a tumor embolus is suspected in the perioperative
period, an angiogram should be performed. Once the
diagnosis is conrmed, removal by an embolectomy is
done if the patient is clinically stable enough to return
to the operating room.
Prevention
If a tumor is suspected pre- or intraoperatively within
the pulmonary vein, a transesophageal echocardiogram
is performed to assess intra-atrial involvement.35,39 At
the time of surgery, the intrapericardial portion of the
pulmonary hilum is explored and assessed for resect-
ability. Another technique described by Taber36 is
placement of a pursestring suture in the left atrium and
transatrial digital palpation. If the tumor involves the
left atrium or distal pulmonary vein, it may be removed
with or without cardiopulmonary bypass.35,38,39 Figure
675 shows a management algorithm described by
Whyte and colleagues in 1992.38
Ligation of the Pulmonary Artery
Pulmonary Artery Embolism/Thrombosis
In 1966, Chuang and coworkers40 reported that approxi-
mately 1% of all pneumonectomy patients had a pulmo-
nary embolus originating from the pulmonary arterial
 67 PNEUMONECTOMY 697

Palpable tumor
within pulmonary vein
(consider intracardiac tumor)

Intraoperative
transesophageal ECHO
digital palpation through
left atrial pursestring suture

Intracardiac
tumor

Yes No

Wedge resection of left Intrapericardial

atrium using endo ligation of vein
stapling device
Resection of CPB
Unresectable
Tumor within line
of transection

Yes
No

Neurological Peripheral EKG Visceral

exam vascular angiography for
exam any abdominal
symptoms

Normal Abnormal No change Acute

from preop ischemia Negative Embolus

Carotid Embolectomy No Acute Embolectomy

duplex scan change ischemia or
abdominal
exploration

Head CT Possible carotid Coronary

Medical embolectomy angiography
management if tumor lodged
in extracranial
carotid artery
Medical Coronary
management revascularization
of MI

Figure 675 Peripheral tumor embolus algorithm. (From Whyte RI, Starkey TD, Orringer MB. Tumor emboli from lung neoplasms
involving the pulmonary vein. J Thorac Cardiovasc Surg 1992;104:421425.)

stump. It occurs more commonly on the right, possibly Repair

secondary to the longer arterial stump.41
Consequence
Overall, pulmonary artery embolus is the fourth leading
cause of death in pneumonectomy patients.42
Grade 1/3 complication
Initial treatment of pulmonary arterial thrombosis is
the same as with any postoperative patient with a pul-
monary embolus, including supportive care and anti-
coagulation. If the patient is hemodynamically unstable,
either a pulmonary embolectomy or a catheter-based
treatment may be an option.
 698 SECTION XI: THORACIC SURGERY
Prevention
The exact etiology of a pulmonary embolus originating
from the pulmonary arterial stump is unknown, but it
is believed that appropriate arterial closure with a non-
absorbable suture or stapler may decrease the inci-
dence. Also, postoperatively, prevention should include
early mobilization, sequential compression devices,
and/or subcutaneous anticoagulation.
Closure of the Bronchus
Empyema with or without BPF
The incidence of empyema after pneumonectomy is
between 2% and 16%.4,43 A BPF is commonly but not
always associated with empyemas. In a series from the
Mayo Clinic in 2001,31 53 (7.5%) of 713 pneumonectomy
patients developed postoperative empyemas and 32
(4.5%) had associated BPF. Risk factors for developing
BPF include right-sided pneumonectomy, completion
pneumonectomy, preoperative radiation therapy, pneu-
monectomy for inammatory or infectious disease,
residual/recurrent tumor, and intraoperative technical
factors. A BPF can develop early (17 days), secondary to
technical factors, or up to years later from multiple differ-
ent factors.44,45
Consequence
Mortality in patients with an empyema and BPF has
been reported to be between 16% and 72%.46 Signi-
cant morbidity associated with BPF includes increased
hospital stay, long rehabilitation, and recurrent opera-
tive procedures.
Grade 3/4 complication
Repair
The initial management of patients suspected of having
empyema with or without BPF includes stabilization of
the patient, accurate diagnosis, and denitive treat-
ment, including adequate pleural drainage, parental
A B
Figure 676 Dbridement of the bronchial stump.
antibiotics, nutritional support, removal of necrotic
tissue, and obliteration of the residual pleural space.45
If the patient presents acutely ill with signs of respira-
tory distress, she or he should be placed in the lateral
decubitus position with the operative side down to
prevent contamination of the contralateral lung. Once
the patient has been stabilized, denitive treatment
options include thoracoplasty, open pleural drainage,
anterior transpericardial closure of the stula, oblitera-
tion of the empyema space with uid or muscle, primary
closure of the bronchial stump with vascularized tissue,
or the use of a continuous irrigation system.4752
At the Mayo Clinic, a combination of the original
Clagett technique and the use of a well-vascularized extra-
thoracic muscle is used to cover the bronchial stump.53,54
After initial stabilization, which may include tube thora-
costomy, the patient is returned to the operating room
and the thoracotomy is reopened. The BPF is identied
by lling the pleural cavity with uid and observing for
leakage of air bubbles. Once the BPF is identied, it is
dbrided and reclosed near the carina with interrupted
nonabsorbable sutures to prevent a long stump (Fig. 67
6). A well-vascularized muscle ap is then used to cover
the bronchial stump (Fig. 677). Options for the muscle
ap include serratus anterior, latissimus dorsi, pectoralis
major, or rectus abdominis. If the empyema exists without
a BPF, muscle ap is not required but may be used to
protect underlying structures. The remainder of the pleural
cavity is irrigated, dbrided, and packed with wet dressings
(Fig. 678). Irrigation and dbridement are repeated
every 48 hours in the operating room until the pleural
cavity is clean with good granulation tissue. The cavity is
then lled with dbridement antibiotic solution (DABS)
(0.5 g neomycin, 0.1 g polymyxin B sulfate, and 80 mg
gentamicin per liter of saline) and closed (Fig. 679).45
Prevention
The bronchial stump should be handled gently to avoid
devascularization and should not be left excessively
 67 PNEUMONECTOMY 699

A B

A B
Figure 677 Serratus anterior muscle ap to cover a broncho-
pleural stula (BPF).

Figure 678 Dbridement and packing of the pleural cavity.

long. No single technique of closure of the bronchial
stump has been shown to be superior. The series from
the Mayo Clinic31 showed a decrease in BPF with
stapled versus hand-sewn closure of the bronchus.
al-Kattan and associates55 had a 1.3% BPF rate in 530
pneumonectomies using interrupted nonabsorbable
monolament 2-0 polypropylene sutures. Also, the
prophylactic use of a vascularized muscle ap is not
clear. Deschamps and coworkers31 showed an increased
incidence of BPF with the use of bronchial stump rein-
forcement in 2001, but this was not a randomized trial
and the patients that had prophylactic muscle aps were
believed to be at signicantly higher risk. It is generally
recommended that patients having a pneumonectomy
for inammatory of infectious disease or those who
received neoadjuvant radiation therapy should have a
muscle ap to cover the bronchial stump at the initial
procedure.

Postoperative Complications
Cardiac Arrhythmias
Postoperative cardiac arrhythmias occur in 14% to 40% of
pneumonectomy patients.56 The majority of these arrhyth- Figure 679 Filling of the pleural cavity with dbridement anti-
mias are atrial in origin, with atrial brillation being the biotic solution (DABS).
 700 SECTION XI: THORACIC SURGERY
most common. Predisposing factors include advanced age,
coronary artery disease, and more extensive procedures
(e.g., extrapleural pneumonectomy). The exact etiology is
unclear, but it probably results from a combination of
factors including hypoxia, vagal stimulation, electrolyte
imbalances, abnormal blood pH, reduced pulmonary vas-
cular reserve, local inammation of the atria, distention of
the atria, and general anesthesia.56
Consequence
Cardiac arrhythmias are associated with an up to 40%
increased perioperative mortality.56 They may also lead
to an increased length of intensive care unit and overall
hospital stay.
Grade 1 complication
Repair
Patients should have continuous cardiac monitoring
postoperatively to help identify these arrhythmias.
Ritchie and colleagues57,58 showed that over half of
these arrhythmias occurred in the rst 24 hours after
surgery. Once the diagnosis has been conrmed, the
patient should be stabilized and treated appropriately.
This may include -blockers, calcium channel blockers,
digoxin, or electrical/chemical cardioversion.
Prevention
Prophylactic treatment of arrhythmias in the postop-
erative setting has been examined in multiple studies.
The early studies using digoxin showed benet, but
this was not conrmed in more recent studies.5760
Borgeat and coworkers61 looked at the use of ecainide
as a continuous infusion and found a decrease in the
incidence of arrhythmias, but the regimen was compli-
cated and intravenous ecainide is not available in
the United States. Amiodarone has also been studied
with conicting results.62,63 Some believe that the pul-
monary complications of amiodarone in the setting of
a pneumonectomy outweigh the potential benet. Van
Miegham and associates64 and Amar and colleagues65
showed a decrease in postoperative arrhythmias with
calcium channel blockers.
No single study has been absolutely conclusive; there-
fore, the prophylactic use of any of these medications is
not routine.
Postpneumonectomy Pulmonary Edema
Postpneumonectomy pulmonary edema (PPE) is a condi-
tion that occurs in the early postoperative period (usually
within 72 hours), in which patients develop rapidly pro-
gressive hypoxia and inltration of the contralateral lung.66
The incidence is between 3% and 5% of pneumonectomy
patients and the mortality approaches 80% to 100%.66,67
Risk factors include right pneumonectomy, duration of
surgery, extent of surgery, perioperative uid overload,
and postoperative pleural drainage.6669
Initially, patients present with dyspnea that rapidly
progresses despite optimal treatment, and they require
mechanical ventilation within 12 to 24 hours after the
Figure 6710 Chest radiograph of a right-sided postpneumonec-
tomy pulmonary embolism (PPE).
onset of symptoms. The chest radiograph will quickly
develop picture consistent with acute respiratory distress
syndrome (ARDS) (Fig. 6710).
Consequence
Even with early diagnosis and aggressive treatment, the
mortality approaches 80% to 100%.66,67
Grade 4/5 complication
Repair
Once the patient begins to develop dyspnea and
hypoxia, the differential diagnosis should include car-
diogenic pulmonary edema, aspiration pneumonitis,
infectious pneumonitis, pneumonia, massive atelectasis,
pulmonary embolus, sepsis, and PPE. Normally, the
patient is transported to the intensive care unit and
supported with mechanical ventilation, but there have
been reports of treatment with continuous positive
airway pressure (CPAP) masks.70 Bronchoscopy, pul-
monary artery catheter monitoring, pan-cultures with
the initiation of empirical broad-spectrum antibiotics,
and computed tomography (CT) scans of the chest
should be performed to rule out other causes of the
hypoxia. Normally, the patients require elevated levels
of inspired oxygen and higher airway pressures to main-
tain adequate oxygenation. Pressure control ventilation
may aid in decreasing the volutrauma associated with
the mechanical ventilation in these patients. Nutritional
support should also be started as soon as possible.
Other therapies that have been described but have
not been shown to have consistent improvement include
steroids, extracorporeal membrane oxygenation (ECMO),
and inhaled nitrous oxide.66,71,72
Prevention
The etiology of PPE is not fully understood; there-
fore, no denitive prevention is known. In the initial

Figure 6711 Preoperative computed tomography (CT) scan of
the chest in right-sided postpneumonectomy syndrome (PPS).
postoperative period, uid restriction with the use of
diuretics has been generally accepted. Intravenous uid
rates are kept between 30 and 50 ml/hr.73 Otherwise,
standard postoperative care of the thoracic patient
should include adequate pain control, early mobiliza-
tion, and pulmonary rehabilitation.
Postpneumonectomy Syndrome
Consequence
Postpneumonectomy syndrome (PPS) results from
major airway compression secondary to progressive
mediastinal shift toward the side of the pneumonec-
tomy. This leads to stretching and/or compression of
the trachea or main stem bronchus. PPS is more com-
monly associated with right-sided pneumonectomies,
and PPS after a left pneumonectomy is usually associ-
ated with a right-sided aortic arch.74,75 Although Shamji
and coworkers76 reported a series of patients with PPS
after left pneumonectomy and normal aortic arch
anatomy. The right-sided PPS is secondary to a coun-
terclockwise rotation of the heart and great vessels,
leading to stretching of the left main stem bronchus
with compression between the aorta and the pulmo-
nary artery (Fig. 6711). Left PPS has a clockwise
rotation of the heart and mediastinum with compres-
sion of the right main stem bronchus over the vertebral
body.
PPS may present early or several years later. Shepard
and associates77 reported a case of right PPS 37 years after
resection. Other risk factors associated with PPS are young
age and female gender, likely secondary to increased elas-
ticity of the mediastinum in these patients.74
Grade 3 complication
Repair
The presentation of PPS is usually one of a slow pro-
gressive increase in dyspnea associated with repeated
67 PNEUMONECTOMY 701
Figure 6712 Bronchoscopic view of a patient after right pneu-
monectomy with a narrowed left lower lobe orice.
episodes of respiratory infection, coughing, and
stridor.74 Initially, a chest radiograph may suggest the
diagnosis, but it is conrmed with bronchoscopy and
CT scan. The bronchoscopy may reveal narrowing of
the airway or tracheobronchial malacia (Fig. 6712).
Once the diagnosis has been conrmed, treatment con-
sists of stabilization of the patient, dissection of the
adhesions on the operative side, placement of a pros-
thetic device, and correction of the tracheobronchial
malacia if present. Many different materials have been
described for expansion of the pleural space, but the
best results appear to be with an expandable saline
prosthesis (Figs. 6713 and 6714).75,76,7881 The tra-
cheobronchial malacia has been treated with expand-
able metallic stents.8284
PlatypneaOrthodeoxia Syndrome
Platypnea is a very rare complication after pneumonec-
tomy: only 39 cases had been reported in the literature as
of 1998.85 The rst report was in 1956 by Schnabel and
colleagues.86 Clinically, the patient presents with dyspnea
and hypoxia while sitting upright or standing. In the
supine position, the dyspnea and hypoxia are either absent
or signicantly decreased. The etiology is increased right-
to-left shunting at the atrial level secondary to a patent
foramen ovale (PFO) or atrial septal defect (ASD), which
may or may not have been present preoperatively.85 Pos-
sible causative factors include increased pulmonary vascu-
lar resistance, decreased right ventricular compliance, or
rotation of the heart with distortion of ow from the
 702 SECTION XI: THORACIC SURGERY
Figure 6713 Intraoperative photograph after placement of a
saline implant in a patient with right-sided PPS.
Figure 6714 Postoperative CT scan of the chest in a patient
with right-sided PPS.
inferior vena cava.85 This leads to right-to-left shunting
associated with increased intrathoracic pressures during
sitting or standing.
Consequence
Platypnea is usually insidious in presentation and may
be quite complex to diagnose because most pneumo-
nectomy patients have some degree of dyspnea. There-
fore, the diagnosis may be delayed along with the
patients recovery. Repair of the PFO/ASD corrects
the problem and is associated with limited mortality.
Grade 2/3 complication
Repair
The diagnosis can usually be made with transthoracic
echocardiography (Fig. 6715), but occasionally, a
right heart catheterization is required to demonstrate
the defect. The PFO is then repaired surgically or with
a percutaneous closure device.8588
Figure 6715 Intraoperative transesophageal echocardiogram of
a patent foramen ovale (PFO).
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68
Chest Wall Resections
Jessica S. Donington, MD
INTRODUCTION
Indications for chest wall resections are listed below,
malignancy is the most common indication today.1 Resec-
tions for malignancy are performed for primary chest wall
malignancies, metastatic spread to the chest wall from
distant sites, or direct extension from lung cancer or breast
cancer. Chest wall resections must be discussed hand-in-
hand with reconstruction. The tenets of chest wall resec-
tion and reconstruction are (1) remove all malignant or
devitalized tissue, (2) restore rigidity to large chest wall
defects to prevent ail chest, and (3) provide healthy soft
tissue coverage that will seal the pleural space, protect
underlying organs, and prevent infection. Functional
reconstruction can often be more difcult than the resec-
tion for these cases. These patients are best cared for by
a team of physicians, including reconstructive and thoracic
surgeons. Appropriate planning is required prior to the
start of surgery to ensure that adequate margins are
obtained while necessary muscles and soft tissues needed
for reconstruction are preserved.
MAJOR INDICATIONS
Malignancy
Infection
Radiation injury
LESS COMMON INDICATIONS
Congenital abnormalities
Trauma
PREOPERATIVE PREPARATION
Planning and Consultation
Poor Planning and Lack of
Preoperative Consultation
Consequence
Poor planning and lack of preoperative consultation
with a reconstructive surgeon can leave the thoracic
surgeon alone in the operating room with a defect
larger than anticipated and inadequate tissue to restore
chest wall rigidity and provide soft tissue coverage.
Grade 1/2 complication
Repair
Intraoperative consultation is necessary to provide
closure, but it may require extensive operating time and
tissue manipulation if the patient is not appropriately
prepared or positioned. It may necessitate a staged
operation to complete reconstruction.
Prevention
Consult a reconstructive surgeon prior to any chest wall
resection that may result in a wound larger than 4 cm
with concern for soft tissue coverage.
HISTORY
The rst reported chest wall resection was by Aimar in
1778; the next reports are from Parham in 18982 and
Lund in 1913.3 Airway control, positive-pressure ventila-
tion, and closed chest drainage systems were introduced
at the end of the 19th century. These technologies and
the expanded use of antibiotics dramatically advanced the
eld of thoracic surgery. In the 1930s and 1940s, large
series of chest wall resections were published by Hedblom,4
Harrington,5 and Zinniger.6 At that time, operative mor-
tality was as high as 29%. In the 1940s, treatment of
injuries from World War II brought signicant advance-
ments in the management of infected pleural spaces, ven-
tilatory mechanics, and reconstructive techniques with
soft tissue coverage. Fascia lata grafts for large bony defects
and rib grafts for sternal reconstruction were described.7,8
One of the major advancements in chest wall reconstruc-
tion has been the use of musculocutaneous aps. Latissi-
mus dorsi aps for the reconstruction of chest wall defects
after radical mastectomy were rst described by Tansini as
far back as 1906.9 Campbell10 also described use of mus-
culocutaneous aps in the 1950s, but the frequent use of
muscle aps for chest wall reconstruction did not begin
until 1977, when Jurkiewicz and associates11 at Emory
University began using them regularly. Their techniques
are widely used today, and rotational muscle aps are the
workhorses of chest wall reconstruction. All major tho-
 706 SECTION XI: THORACIC SURGERY
racic muscles, including the latissimus dorsi, pectoralis
major and minor, serratus anterior, rectus abdominis, and
external obliques, can be used in chest wall reconstruc-
tion. With use of these modern techniques, autologous
soft tissue coverage is almost always possible, even for the
most aggressive chest wall resections.
This chapter specically addresses chest wall resections
for primary chest wall tumors and chest wall resections
performed en bloc with lung resections for direct exten-
sion from a bronchogenic carcinoma, with special consid-
eration to Pancoasts tumors and sternal resections for
infection.
Resection of Primary
Chest Wall Tumors
Chest wall tumors generally present as slowly growing
asymptomatic masses. Fifty percent to 80% of primary
chest wall tumors are malignant. The most common
malignant tumors of the chest wall are malignant brous
histocytomas (MFH), chondrosarcoma, and rhabdomyo-
sarcomas. The most common benign tumors are chondro-
mas, osteochondromas, and desmoid tumors.1,12 Evaluation
of patients with chest wall tumors includes a history and
physical examination and conventional x-rays compared
with previous x-rays, if available, to document rate of
growth. In general, magnetic resonance imaging (MRI)
is the preferred method for imaging primary chest wall
malignancies. MRI allows visualization of the tumor in
multiple planes and is superior to computed tomography
(CT) at distinguishing tumor from nerves and vasculature.
CT also plays a vital role because it is superior to MRI for
evaluation of the pulmonary parenchyma for metastatic
involvement. Each resection is unique, but the basic steps
of the operation are outlined here.
OPERATIVE STEPS
Step 1 Biopsy
Step 2 Determine necessary resection margin
Step 3 Consider consultation with reconstructive
surgeon
Step 4 Epidural catheter, double-lumen endotracheal
tube, and positioning
Step 5 Skin incision
Step 6 Dissection to chest wall
Step 7 Enter pleural space
Step 8 Palpate tumor inside of chest
Step 9 Divide intercostal muscles
Step 10 Resect ribs
Step 11 En-bloc resection of involved underlying
structures
Step 12 Chest tube insertion
Step 13 Mesh reconstruction of bony chest wall
Step 14 Soft tissue coverage
Step 15 Skin closure
Biopsy
Primary chest wall tumors require tissue diagnosis prior to
treatment. A well-performed biopsy is one of the keys to
the successful management of these tumors. An incor-
rectly placed biopsy or inadequate tissue sampling can
severely compromise treatment. To allow for proper tech-
nique and placement, it is best if the surgeon who will
perform the denitive resection also performs the biopsy.
The biopsy needs to allow for maximal tissue for patho-
logic evaluation; small incisional biopsies and needle biop-
sies obtain limited amounts of tissue and can lead to
misdiagnosis of low-grade malignancies. At tertiary cancer
centers, core needle biopsy for diagnosis has been advo-
cated, but only with the support of a specialized cytopa-
thologist.13 At most other institutions, excisional biopsies
are preferred for tumors smaller than 4 cm. The best
chance for cure of low-grade malignancies is wide resec-
tion; without an adequate amount of tissue for diagnosis,
the opportunity for cure can be missed. For tumors larger
than 4 cm, an incisional biopsy is usually necessary. The
skin incision for the biopsy needs to be placed so that it
can be completely removed at the time of denitive resec-
tion and does not compromise any of the soft tissue or
vasculature necessary for reconstruction. Soft tissue dissec-
tion should be minimal; tissue aps should not be raised.
The capsule of the mass should be closed after the biopsy
to reduce tumor spillage. Careful operative technique is
essential. A wound infection can signicantly delay che-
motherapy, radiation therapy, or denitive surgery, and a
hematoma can lead to signicant soft tissue contamina-
tion, resulting in a larger denitive resection.
Incorrectly Performed Biopsy
Consequence
Incorrectly performed biopsies can result in inadequate
tissue for diagnosis, contaminated tissue planes, and
unnecessary sacrice of skin and soft tissue.
Grade 2/3 complication
Repair
Denitive diagnosis is imperative, and a repeat biopsy
may be needed if only a small tissue sample was obtained
at the initial biopsy attempt. Because complete resec-
tion with wide margins is essential for cure, an improp-
erly performed biopsy can lead to a signicantly larger
resection in order to encompass all tissue violated by a
biopsy or to postbiopsy hematoma or infection.
Prevention
The surgeon who performs the resection should ideally
perform the biopsy. In masses smaller than 4 cm, exci-

sional biopsy should be undertaken with plans to return
for wider denitive resection if a malignant diagnosis is
obtained. Incisional biopsy is used for larger tumors.
The biopsy should be made as directly over the mass
as possible, taking into account that the entire biopsy
site will need to be removed with the denitive resec-
tion. Care should be taken to avoid vascular pedicles
to musculature, which may be needed for reconstruc-
tion. Careful surgical technique and homeostasis are
essential to minimize postbiopsy hematoma or infec-
tion. If incisional biopsy is needed because of tumor
size, it is important that skin aps are not raised and
that the deep plane of the tumor, especially the pleural
surface, is not disturbed. This needs to be left intact to
prevent dissemination of tumor cells.
Resection
When a diagnosis has been made, denitive resection can
be carried out. The surgical approach is dictated by the
location, histology, and extent of overlying soft tissue
involvement. Preoperative assessment by a reconstructive
surgeon is essential for many of these resections. An epi-
dural catheter is recommended for those resections that
do not involve the spine. A double-lumen endotracheal
tube should be used to selectively deate the ipsilateral
lung; this helps to avoid lung injury, facilitates wedge
resections, and allows for manual palpation of the lung to
rule out metastasis. Decubitus positioning is used for most
thoracotomies, but it may need to be modied in these
cases based on the location of the mass. If a muscle ap
is needed for closure, it must be considered prior to posi-
tioning and draping the patient.
Obtaining adequate resection margins is essential to
minimize the risk of local recurrence. The extent of resec-
tion should not be limited by the size of the resulting
defect. The appropriate margin of resection for primary
chest wall tumors varies depending on the type of neo-
plasm. High-grade tumors, such as MFH and osteogenic
sarcomas, have the potential to spread within the bone
marrow and along the periosteal tissue planes. Therefore,
the entire involved rib, the corresponding anterior costal
margin for anterior tumors, and partial resection of the
ribs above and below the neoplasm should be removed.
Resection of the entire sternum and bilateral costal arches
is indicated for malignant tumors of the sternum. Less
aggressive primary chest wall malignancies should be
resected with at least 4-cm margins. In a Mayo Clinic
review14 of survival after resection of primary chest wall
malignancies, 56% of patients with margins 4-cm or greater
were cancer free at 5 years compared with only 29% of
those patients with 2-cm margins. Any attached structures
including lung, thymus, pericardium, or overlying chest
wall musculature, should be resected en bloc with malig-
nant chest wall tumors. If there is any involvement of the
overlying skin, at least a 1-cm margin of normal skin is
recommended.15
68 CHEST WALL RESECTIONS 707
Most low-grade lesions and benign tumors can be
resected with 2- to 3-cm margins. The exceptions to this
are desmoid tumors, which are classied as low-grade
malignancies but are locally very aggressive and have a
very high rate of local recurrence. These are, therefore,
managed surgically like malignant chest wall lesions, and
4-cm resection margins are recommended.16
When the skin is involved, the incision is dictated by
that involvement, and full-thickness resection of skin,
muscle, and chest wall is undertaken in a cookie cutter
fashion. If the mass does not involve the overlying skin
and soft tissue, a standard thoracotomy-type incision can
be made in the area over the mass and aps can be care-
fully raised and used for closure. One normal musculofas-
cial plane should be included in the resection, but
uninvolved tissues can be spared.17
The pleural space should be entered one full rib space
above or below the involved tumor. The mass should be
palpated on the underside of the chest wall to determine
margins of resection (4 cm from the mass for malignant
tumors and 23 cm for benign) (Fig. 681). Any attached
structures should be resected en bloc. The lung should be
palpated to evaluate for pulmonary metastases. Once the
margins have been determined, the bony resection is
undertaken. Electrocautery or the periosteal elevator can
be used to lift the intercostal musculature and neurovas-
cular bundle from the ribs at the superior and inferior
margins of resection. At the anterior and posterior margins,
cautery is used to clear a 1- to 2-cm length at each rib
(Fig. 682). The intercostal neurovascular bundle can be
divided with cautery or between clips through that space.
A guillotine or shear rib cutter is used to divide the ribs.
A 1-cm segment of each rib should be removed at the
resection margin and submitted for pathologic examina-
tion after decalcication (Fig. 683). Any questionable
soft tissue margin should be submitted for frozen section
evaluation. One cannot overemphasize the importance
Figure 681 The surgeon palpates the tumor inside of the chest
to determine the margins of resection.
 708 SECTION XI: THORACIC SURGERY
Figure 682 The intercostal muscles and neurovascular bundles
are cleared with electrocautery over a 2- to 3-cm length at each
rib space.
Figure 683 The technique for the division or ribs with rib
shear, sending 1-cm margin from each rib for evaluation after
decalcication.
of a wide resection with clear margins at the primary
resection.
Reconstruction
The goals of reconstruction include restoring the struc-
tural stability of the thorax and providing soft tissue cov-
erage. In general, defects smaller than 4 cm do not require
reconstruction of the bony portion of the chest wall. Full-
thickness defects of the chest wall greater than 4 cm
require reconstruction. The exception is high posterior
defects, because the overlying scapula provides support.
Defects located near the tip of the scapula need to be
reconstructed to prevent impingement of the scapula with
arm movement, which can be painful. The choice of mate-
rial for reconstruction remains controversial. Autologous
tissues such as fascia lata and ribs have been used,7,8 but
Figure 684 Mesh replacement is xed with large monolament
suture around the ribs at the upper and lower extent of resection
and through drilled holes in the cut ribs. The mesh is best xed to
the underside of the chest wall, so it is not pushed away from the
chest wall with each breath.
prosthetic meshes are used most commonly today. The
prosthetic materials most frequently used are polypropyl-
ene mesh (Marlex; Bard, Cranston, RI) and polytetrauo-
roethylene (PTFE/Gore-Tex; W.L. Gore and Associates,
Newark, DE). The Marlex mesh has interstices that allow
for ingrowth of brin. It can be used in two layers with
methyl methacrylate as a sandwich for contoured recon-
structions. Marlex is not watertight. Gore-Tex is water-
tight and required when the skeletal resection accompanies
a pneumonectomy, so that the pneumonectomy space can
ll with uid. Otherwise, both work equally well and are
used at the surgeons discretion. In situations in which
infection is present or the viability of soft tissue coverage
is questionable, the newly available acellular dermal
matrixes (Derma Matrix; Musculoskeletal Transplant
Foundation, Edison, NJ), derived from cadaver skin, can
be used to provide structural support to the chest wall.
The mesh or dermal matrix is sewn in place with heavy
monolament suture. It should be anchored around the
ribs at the inferior and superior margins. To facilitate
xation of the anterior and posterior margins without
compromise of neurovascular structures, drilled holes in
the ribs are recommended. These should be placed at least
1 cm back from the resection margin (Fig. 684). A hand-
held pneumatic drill is preferred to towel clips and rib
punches because it creates less crush injury to the bone
(Fig. 685).
If the chest wall musculature has been removed, direct
skin closure over the prosthesis is not recommended.
Muscle or other soft tissue coverage is necessary and can
be provided via a pedicled rotational ap from the pecto-
ralis major or minor, serratus, latissimus, or rectus muscles.
If those muscles are inadequate or not available, an
omentum or a muscular free ap is used. The majority of
large defects do not result in impairment of respiratory
mechanics when properly reconstructed. Large anterior
defects are most likely to create any risk of respiratory

A ment on CT or PET scan at station 2R, 4R, 2L, 4L,
B
Figure 685 A young male with a recurrent desmoid tumor of
the right lateral chest wall. A, The resulting chest wall defect after
resection. B, Patch reconstruction of the bony chest wall with
dermal matrix.
compromise, secondary to the resulting weak cough and
retention of secretions. Aggressive postoperative pulmo-
nary toilet and bronchoscopy may be necessary in these
patients. There is no advantage to empirically prolonged
postoperative intubation; it provides no increase in stabil-
ity of the reconstruction. Every effort should be made to
extubate these patients in the operating room.
Chest Wall Resections
for Lung Cancer
Lung cancer is the leading cause of cancer death world-
wide, with greater than 1 million new cases each year. Five
percent to 8% of patients with nonsmall cell lung cancer
(NSCLC) have contiguous chest wall involvement.18 His-
torically, these tumors were considered unresectable until
Colemans series in 1947.19 Five patients survived, and
two had long-term cure after resection of a lung with
68 CHEST WALL RESECTIONS 709
en-bloc removal of the chest wall for lung cancer. These
are currently recognized as T3 tumors. In the absence
of lymph node metastasis, survival rates after complete
resection are 45%.20 The most common presenting
symptom is pain, which occurs in 37% to 75% of
patients.19,21,22
Preoperative evaluation includes the standard evalua-
tion for patients undergoing NSCLC operations. This
includes staging and metastatic work-up with CT and
positron-emission tomography (PET), cardiopulmonary
evaluation, and determination of pulmonary reserve with
pulmonary function tests. In general, mediastinoscopy is
performed at the discretion of the surgeon; however, if
there is any suspicion of mediastinal lymph node involve-
or 7, mediastinoscopy is a necessity prior to resection.
Patients who are found to have N2 disease should con-
sider chemoradiotherapy as either induction or denitive
therapy.
Appropriate anticipation and preparation for chest wall
resection is one of the keys to a successful operation. Signs
of chest wall invasion on CT include evidence of rib
destruction, obliteration of the extrapleural fat pad, an
obtuse angle of interface between the tumor and the chest
wall, extended length of the tumor-pleural interface, and
the relation between the length of that interface and the
size of the tumor.23,24 MRI can be useful, as in primary
chest wall tumors; it is superior to CT at delineating soft
tissue invasion (Fig. 686).
OPERATIVE PROCEDURE
Once the preoperative staging work-up is complete, the
patient can move to thoracotomy. Some surgeons advo-
cate thoracoscopy to evaluate for chest wall invasion.25
This step is largely unnecessary unless the tumor is so large
that there is concern about where to safely enter the chest
cavity. Thoracoscopy is an inadequate tool to assess chest
wall invasion or to resect these aggressive tumors. Stan-
dard thoracotomy can be performed with care taken to
enter the chest away from the area of chest wall involve-
ment. Once inside the pleural space, evaluation for chest
wall invasion is the rst step and vital to good outcome.
If only imsy, inammatory-type adhesions are present,
they can be gently taken down or removed by extrapleu-
ral dissection. If there is any concern of invasion into the
chest wall, an en-bloc resection should be performed.
Numerous studies have demonstrated that an extrapleural
dissection in this situation is inadequate.2628 Inappropri-
ate evaluation at this point can be costly, because frozen
section evaluation of the chest wall margin is not very
useful. There is typically a large tissue plane, and signi-
cant sampling error can occur. Complete resection is one
of the main determinants of long-term survival29; there-
fore, this initial assessment is extremely important and
should be performed with great care.
 710 SECTION XI: THORACIC SURGERY

C B
Figure 686 The computed tomography (CT) scan (A), positron-emission tomography (PET) scan (B), and magnetic resonance imaging
(MRI) (C) from a 65-year-old man with a T3N0M0 bronchogenic carcinoma of the right upper lobe involving the posterior aspects of ribs
3, 4, and 5. The patient presented with right-sided back pain.

Determine Necessary Resection Margin

Inaccurate Evaluation and Incomplete Resection
Consequence
Inaccurate evaluation of chest wall invasion can lead to
an incomplete resection that is typically not detected
until the nal pathologic evaluation. Incomplete resec-
tion is one of the main determinants of poor survival.
Grade 4 complication
Repair
If, while taking down lmy adhesions or performing
extrapleural dissection, there is any signicant resis-
tance from the tissues, the dissection should be aborted
and en-bloc chest wall and lung resection performed,
including wide resection of the chest wall around the
area of dissection.
Prevention
The surgeon should have a low threshold for removal
of the chest wall en bloc with a closely adherent lung
cancer because of the overwhelming importance of
negative surgical margins for long-term survival.
Dissection to the Chest Wall
Once the determination for the need of a chest wall resec-
tion is made, the procedure starts; this includes formal
lobectomy with complete hilar and mediastinal dissection
and chest wall resection. The extent and location of chest
wall involvement dictate the order of the procedure.
Often, the chest wall resection is done rst and dropped
into the chest to provide hilar exposure. If the tumor is
very large and its bulk hinders exposure to the hilum, a
stapler can be red through the normal lung to wedge the
mass out and provide exposure for the lobectomy. Most
of these operations are best approached through a stan-
dard posterolateral thoracotomy to allow maximal expo-
sure to the hilum of the lung for the lobectomy and
mediastinal lymph node dissection. Exposure for the chest
wall resection may require extension of that incision and
division of both the latissimus and the serratus muscles.
The rib spreader can provide exposure to the chest wall
by placing one blade in the rib space and the other under
the chest wall musculature. For upper lobe tumors, the
inferior blade is placed in the rib space and the cephalad
blade is placed under the tip of the scapula (Fig. 687).

Figure 687 Rib spreader placed with the inferior blade in the
rib space and the cephalad blade retracting the scapula upward to
expose the chest wall for resection of an upper lobe tumor invad-
ing the chest wall.
As the retractor is opened, it lifts the scapula and chest
wall musculature off the chest wall, similar to opening the
hood of a car. For lower lobe tumors that involve the chest
wall below the thoracotomy, the upper blade of the rib
spreader is placed in the rib space and the more caudal
blade is used to retract back the skin and the overlying
chest wall muscles. Without the scapula there, perforating
towel clips can be used to keep the rib spreader from
slipping.
Inappropriate Placement of the Skin Incision
and Thoracotomy
Consequence
Placing the skin incision and thoracotomy over the area
of chest wall involvement may facilitate the rib resec-
tion, but it will make the lobectomy and mediastinal
lymphadenectomy technically challenging.
Grade 1/2 complication
Repair
If the entrance into the pleural space is too high or too
low to allow for safe and complete hilar dissection for
the lobectomy, a second thoracotomy can be made
through the same skin incision at the fth intercostal
space to facilitate the lobectomy and mediastinal lymph
node dissection.
Prevention
A better approach is to perform a generous, standard
posterolateral thoracotomy, which provides the best
exposure to the hilum for the lobectomy, and use the
rib spreader with one blade in the rib space and the
other under the chest wall musculature to provide
exposure for the chest wall resection. The exception is
68 CHEST WALL RESECTIONS 711
anterior Pancoasts tumors, which often require two
incisions.
Enter the Pleural Space
The chest wall is removed with at least a 2-cm margin.
Margins do not need to be as wide as those for primary
chest wall tumors. The resection of the bony chest wall
proceeds as described in the previous section. The overly-
ing chest wall musculature does not need to be resected
unless it is directly involved with the tumor. The principles
of reconstruction are also similar to those described in the
previous section. Small bony defects and those under the
protection of the scapula do not require reconstruction;
others are reconstructed with a mesh or dermal matrix
patch.
Tumors near the spine require special attention. Tumors
that invade the spine are T4 and require consultation with
a spinal surgeon. For tumors that approach the spine but
do not invade it, the rib can be disarticulated from its
transverse process or the head of the rib can be resected
en bloc with the transverse process using an osteotome.
To perform either maneuver, the paraspinous muscles,
costotransverse ligaments, and costovertebral ligaments
are lifted off the exterior of the chest wall with cautery
past the midline to expose the joints. Inside the chest, the
parietal pleura is elevated off of the anterior spinal column
and resected with the tumor. The joint is disarticulated or
resected ush against the vertebral body, and the rib is
pushed anterior into the chest. This will expose the nerve
root, which is clipped and divided close to where it exits
the canal. Inappropriate traction at this location or mis-
management of the nerve root can result in an iatrogenic
subarachnoid pleural stula. This can result in a large
pleural effusion as a result of cerebrospinal uid (CSF)
leak, tension pneumocephalus, or meningitis.
Excessive Traction and Avulsion of the Dorsal
Nerve Roots
Consequence
Excessive traction and avulsion of the dorsal nerve roots
as they exit the spinal canal can result in a dural tear
and a communication between the intracranial vault
and the pleural space. This can result in a postoperative
CSF leak, tension pneumocephalus, or meningitis.
Grade 2/3 complication
Repair
Subarachnoid pleural stulas that are not recognized in
the operating room are usually discovered in the rst
postoperative week,30 when patients present with exces-
sive chest tube output or neurologic symptoms. Con-
servative management involves antibiotics, bedrest with
a at head position, and placement of a chest tube to
water seal.31 Suction on the chest tube should be
avoided when possible to prevent CSF extravasation,
 712 SECTION XI: THORACIC SURGERY
but resolution of pneumothorax is an important part
of treatment. Therefore, low suction may be necessary
if the air leak is signicant.30 These maneuvers usually
result in an improvement in symptoms within 48 hours.
Fistulas that persist for longer than 2 weeks require
surgical intervention.31 Surgical strategies for repair
include laminectomy with placement of an intradural
or extradural patch32 or thoracoplasty with proximal
nerve ligation.33 Others advocate the use of brin
sealant.34
Prevention
Care should be taken to avoid undo traction on the
dorsal nerve roots. They should be carefully identied
as the rib is separated from the spine and ligated
between vascular clips. If a stula is recognized in
the operating room, the neural foramen can be packed
with muscle and conservative management initiated
postoperatively.
Bleeding from the Intercostal Artery
Bleeding from the intercostal artery can be bothersome at
this location, and care needs to be taken to properly iden-
tify and ligate or clip these vessels prior to transecting.
Again, undo traction on the ribs can result in avulsion.
Cautery in this area should be performed with bipolar or
between pickups to avoid thermal injury.
The routine use of radiation therapy either preopera-
tively or postoperatively in patients with chest wall involve-
ment but without N2 disease remains controversial.
Preoperative therapy has the potential benet of down-
staging tumors and making an unresectable tumor resect-
able, but the majority of tumors invading the chest wall
are resectable at presentation. Preoperative chemoradio-
therapy has been shown to be very useful in the manage-
ment of Pancoasts tumors,35 but this approach has not
been investigated for other patients with chest wall involve-
ment. To date, preoperative therapy in patients who have
resectable tumors that invade the chest wall has no proven
benet. In the face of negative surgical margins, postop-
erative radiation therapy to the area of chest wall resection
is not recommended.
Pancoasts Tumors
The classic denition of a Pancoast tumor is that of a
carcinoma involving the apex of the chest that causes pain
down the medial aspect of the arm and Horners syn-
drome owing to involvement of the nerve roots in the
lower part of the brachial plexus and the stellate gan-
glion.36 Biologically, Pancoasts tumors are not different
from other NSCLCs; they are unique owing to their loca-
tion. They involve structures that are technically difcult
to approach with surgery, and the extent of resection is
limited by the risk for long-term disability. Therefore,
wide local excision with negative margins can be challeng-
ing. Resection of a Pancoast tumor should include a
lobectomy and removal of the affected chest wall. The
importance of a complete resection with negative margins
cannot be overemphasized. In up to one third of resec-
tions for Pancoasts tumors, a complete resection is not
achieved,37 and survival is no better than if surgery had
not been performed.3739 The use of neoadjuvant chemo-
radiation has signicantly improved the rate of R0 resec-
tion for Pancoasts tumors, as demonstrated in the North
American Intergroup Trial 0160.35 In that trial, complete
resection resulted in a 5-year survival rate of 53% and a
local recurrence rate of only 12%.40 Induction chemora-
diotherapy resulted in a pathologic complete response rate
of 66%, a signicant improvement over historic controls.
No randomized, controlled trial has been done on tumors
of the superior sulcus, and because of their rarity (<5% of
lung cancers), completion of such a trial is unlikely. The
results of the Intergroup Trial form the basis for our treat-
ment today. It demonstrated that induction chemoradia-
tion is safe and well tolerated and results in a high rate
of tumor sterilization, a high rate of complete resection,
and improved local control compared with surgery alone
or preoperative radiation therapy. All patients with supe-
rior sulcus tumors, regardless of symptoms, should be
considered for neoadjuvant chemoradiotherapy prior to
resection.
A complete understanding of the anatomy of the tho-
racic inlet is essential to planning a resection of a superior
sulcus tumor. The thoracic inlet can be divided into three
compartments based on the insertion of the anterior and
middle scalene muscles (Fig. 688). The anterior com-
partment, which is anterior to the anterior scalene muscle,
contains the internal jugular and subclavian veins. The
middle compartment lies between the anterior and the
middle scalene muscles and contains the subclavian artery
and brachial plexus. The posterior compartment is behind
the middle scalene and contains the nerve roots to the
brachial plexus, the stellate ganglion, and the vertebrae.
In general, vascular structures are anterior, and neural
structures are posterior. Recognizing these differences is
key to deciding on the surgical approach. Thorough pre-
operative evaluation of the thoracic inlet and the extent
of tumor involvement is vital in planning this operation.
It is essential to determine whether the tumor is resectable
and the approach that will provide the best chance for a
complete resection. MRI is superior to CT for evaluation
of tumors in this location.41 It allows for evaluation of
the tumor in the sagittal and coronal planes and is superior
in determination of neurovascular involvement. Vascular
involvement was once considered a contraindication to
resection, but in newer series, using the anterior approach
and improved surgical techniques demonstrates that good
survival can be obtained in cases with vascular involve-
ment, as long as R0 resection is obtained.42,43 Resection
and reconstruction of vascular structures are technically
easier from the anterior approach. Spinal involvement was
also considered a contraindication to resection, but with

Figure 688 Schematic representation of the thoracic inlet with
attention to the anterior, middle, and posterior compartments.
Compartments are dened by the insertion of the anterior and
middle scalene muscles. The anterior compartment is anterior to
the anterior scalene and contains the jugular and subclavian veins.
The middle compartment lies between the anterior and the middle
scalene muscle and contains the brachial plexus and subclavian
artery. The posterior compartment lies behind the middle scalene
muscle and contains the dorsal nerve roots, stellate ganglion, and
vertebrae.
newer orthopedic techniques for vertebral resection and
stabilization, long-term survival is also possible in this
group of patients.44 Nerve involvement is still an impor-
tant part of determining resectability. Resection of the T1
nerve root is well tolerated, but resection of the C8 nerve
root or lower trunk of the brachial plexus will lead to loss
of function of intrinsic musculature of the hand and is
discouraged. This type of complex resection is contrain-
dicated in any patient with N2 disease. Five-year survival
is less than 10% in patients with N2 disease.38 Thorough
evaluation of the mediastinal lymph nodes is vital, and
most surgeons recommend mediastinoscopy.
There are two basic surgical approaches to Pancoasts
tumors, the posterior approach described by Shaw and
coworkers in 196145 and the anterior transclavicular-
thoracic or transclavicular approach described by
Dartevelle and colleagues.42 There have been several mod-
ications to the anterior approach, but all with the same
goal: improved exposure to the anterior aspect of the
thoracic inlet. In general, tumors in the anterior and
middle compartments are best treated from an anterior
approach because it allows for better exposure to the
vasculature, whereas tumors involving the posterior com-
partment are best treated via the posterior approach. This
decision as to which approach needs to be made preop-
eratively because positioning is signicantly different.
68 CHEST WALL RESECTIONS 713
OPERATIVE PROCEDURE
Preoperative Evaluation
Inappropriate Preoperative Evaluation
Consequence
Inappropriate preoperative evaluation of the thoracic
outlet and extent of tumor involvement can result in a
poor decision regarding approach and can leave the
surgeon in the operating room with inadequate expo-
sure for either vascular resection and reconstruction or
spinal resection. Complete resection of the structures
is possible and recommended if it will allow for an R0
resection. Negative margins have a signicant impact
on survival.
Grade 4 complication
Repair
If the tumor invades more structures than originally
anticipated and more extensive resection is needed, the
surgeon should consider a second incision from the
other side if it would make an R0 resection possible.
Prevention
Thorough preparation and evaluation of the inlet is
essential in these procedures. The surgeon needs to be
comfortable with both approaches, and preoperative
consultation with a spine surgeon or vascular surgeon
should be anticipated preoperatively.
Posterior Approach
The posterior approach is performed with the patient in
the lateral decubitus position. The incision is an extended
posterolateral thoracotomy. The posterior extension runs
halfway between the scapula and the spine up to the level
of the seventh cervical vertebrae. Chest wall exposure
is achieved by completely dividing the trapezius and
rhomboid muscles. As with other chest wall tumors, the
superior blade of the rib spreader is placed under the
scapula to expose the chest wall. Alternatively, an internal
mammary retractor can also be placed under the tip of the
scapula to elevate it off the chest wall. Dissection begins
by removing the scalene muscles from the upper surface
of the rst and second ribs, making sure to come above
any involved tumor. The inlet can now be evaluated for
invasion of subclavian vessels or brachial plexus. The pos-
terior rib dissection is performed by disarticulating the rib
from the transverse spinal process or by en-bloc resection
of the joint, as discussed in the previous section. This
begins at the inferior aspect of the resection and proceeds
toward the apex. Special care needs to be taken with the
dorsal nerve roots; iatrogenic subarachnoid pleural stulas
occur in up to 1% of apical lung resections.31 The anterior
ribs are also approached inferiorly and moving toward the
apex. The ribs and bony chest wall are divided in the
manner discussed in the rst section. The rst rib is dif-
cult to take with rib shears, and a Gigli saw or oscillating
 714 SECTION XI: THORACIC SURGERY
saw is recommended. The T1 dorsal nerve root can be
taken with the tumor, but sacrice of higher portions of
the brachial plexus will result in functional loss in the
hand. Once the tumor is freed from the apex, the hilar
dissection for the lobectomy proceeds as normal. Recon-
struction of the chest wall defect is rarely necessary because
it is all under the scapula.
Anterior Approach
The anterior approach is performed with the patient
supine with the neck hyperextended and the head turned
away from the involved side. A bolster or roll is placed
under the operative shoulder to elevate the eld. An L-
shaped incision is made along the anterior border of the
sternocleidomastoid and then out horizontally below the
clavicle in the second intercostal space. The sternocleido-
mastoid and pectoralis muscles are dissected off the clav-
icle. The myocutaneous ap is folded back to expose the
anterior portion of the thoracic inlet. The omohyhoid is
divided. The scalene fat pad is resected and inspected for
lymph node involvement. The anterior chest is entered in
a rib space below the tumor to allow palpation for further
evaluation of the tumor involvement. If the tumor is
believed to be resectable, the clavicle needs to be removed
from the eld. The medial half of the clavicle can be
resected or the sternoclavicular joint can be divided and
the clavicle reected laterally. The venous conuence is
then the most supercial structure and is dissected rst.
The internal jugular vein can be ligated to provide expo-
sure, and the subclavian vein can be resected if it is involved
with tumor. On the left side, care needs to be taken to
identify and ligate the thoracic duct as it enters the venous
conuence to avoid a chylothorax. The anterior scalene
muscle is divided off the rst rib, above any tumor involve-
ment. The phrenic nerve needs to be identied as it
courses over the anterior surface of the anterior scalene
and protected. Unnecessary division can lead to a para-
lyzed hemidiaphragm and unwanted respiratory complica-
tions. The subclavian artery will now be visible. If it is
involved with tumor, it needs to be resected. Dissection
is undertaken to achieve good proximal and distal control
away form the tumor. The vessel is cross-clamped and
divided; reconstruction is usually performed with a ringed
Gore-Tex vascular graft when the resection is complete.
The middle and posterior scalene muscles are now divided
above the tumor to expose the C8 and T1 nerve roots.
The T1 nerve root is divided just lateral to the interver-
tebral foramen. Division of the C8 nerve should be avoided
if possible. Through the transclavicular approach, the
chest wall is resected anterior to posterior and superior to
inferior. The rst rib is divided from the sternum at the
costochondral junction, and the second rib is resected
free of involved tumor. The dissection is carried down the
superior surface of the rst uninvolved rib, usually the
third or fourth. Cautery is used to dissect along the supe-
rior border of the uninvolved rib to the costovertebral
angle. The posterior aspect of resection also starts at the
top. The rst rib is then disarticulated from its vertebral
attachments, followed by ribs two and three, again taking
care to identify and clip the dorsal nerve roots prior to
division. At the completion of the posterior chest wall
resection, the specimen should be free from the inlet with
a resulting defect into the chest cavity. It is possible to
perform the hilar dissection for the lobectomy through
the hole, but this can be technically challenging. The
surgeon needs to have a low threshold to close the ante-
rior incision and perform a separate posterolateral thora-
cotomy to complete the resection rather than compromise
any oncologic aspect of the lobectomy and lymph node
dissection.
Infection
The most common infectious indication for chest wall
resection is infected sternal wounds after cardiac surgery.
Sternal wound infection is a rare but devastating complica-
tion of cardiac surgery. These infections can carry signi-
cant mortality if they are not recognized early and treated
with aggressive dbridement. When the median sternot-
omy was introduced for cardiac surgery in 1957, infection
rates were 5%. Infection inevitably led to sternal dehis-
cence, which was associated with a 50% mortality rate.46
Early treatment protocols involved dbridement and
wound packing. Healing with this technique was slow,
and patients frequently died from cardiac rupture or
rupture of a vein graft secondary to continued infection
or desiccation. The introduction of antibiotic irrigation
systems with indwelling catheters was a major advance-
ment that decreased mortality to 20%.4749 Hospital stays
remained unacceptably long, and the risk of vein graft
rupture was still an issue. In the mid 1970s, the concept
of wide dbridement with immediate ap closure was
introduced. Lee and associates50 described the successful
use of an omental ap. Jurkiewicz and colleagues51,52 at
Emory University described the use of pectoralis major
muscle aps; this technique is most widely used today.
This procedure has signicantly decreased the hospital stay
and mortality associated with sternal wound infections.53
With the risk of mediastinitis and cardiac rupture, the
morbidity and mortality associated with infected sternal
wounds are higher than those of many other chest wall
infections, but the principles of management are the same.
The wound should be aggressively dbrided of devitalized
and infected bone and soft tissue and covered early with
healthy, well-vascularized soft tissue.
Early detection and treatment are fundamental to suc-
cessful treatment of sternal wound infections. The patients
who undergo coronary artery bypass grafting continue to
get older and sicker. Therefore, the risk for these types of
infection persist and the risk for resulting multisystem
organ failure remains great. Clinical signs of infection
include exposed wires, sternal instability, wound drainage,
and elevated leukocyte count. Renal function needs to be
carefully evaluated because renal deterioration is often the
rst sign of impending multisystem organ failure.

Treatment begins with wound exploration with the
patient under general anesthesia. The sternotomy wound
is completely reopened. Wound cultures are taken, and all
wires are removed. If infection is found, the sternal edges
are resected until healthy bone with brisk bleeding is
encountered. If the bone is necrotic and oozing pus,
radical removal of the entire sternum is recommended.54,55
Survival with radical sternectomy is superior to dbride-
ment and rexation, with or without an irrigation system.55
Costal cartilages should also be resected if they are necrotic.
This aggressive approach is essential to clearing the infec-
tion and improving survival. As in chest wall resections
performed for cancer, one should not let the magnitude
of the resulting defect limit the extent of an appropriate
resection. Adequate dbridement is the hallmark of a suc-
cessful outcome. Without the sternum to reafx, patients
are left with paradoxical chest wall motion with breathing
and coughing. Muscle ap coverage provides sufcient
stability for normal activity. Pulmonary function does not
differ from that in controls, and there is no added dif-
culty with extubation.56
In the past, muscle ap closure was delayed by several
days to weeks, but now, immediate ap closure is advo-
cated by most. This step has signicantly shortened
hospital stays and decreased mortality.54 Options for soft
tissue coverage include bilateral pectoralis major aps,
latissimus dorsi aps, omentum, or rectus abdominis aps.
Most surgeons favor bilateral pectoralis major aps; these
are large muscles that lie in the operating eld and are
easy to dissect. Rectus abdominis aps are a frequent
second choice. Omentum is very useful and can conform
to the deepest recesses of these wounds but requires a
laparotomy for harvesting. Latissimus dorsi aps can
provide extensive tissue including skin, but they need to
be placed as a free ap.55
CONCLUSION
The most frequent indications for chest wall resection are
cancer, radiation injury, and infection. The basic principles
of successful resection are the same for all indications:
1. Prompt and appropriate diagnosis is essential.
2. Preoperative consultation with a reconstructive surgeon
is necessary for any chest wall resection that may result
in a signicant loss of soft tissue.
3. Adequate margins of resection cannot be overempha-
sized4 cm margins for high-grade sarcomas or resec-
tion of any and all devitalized tissue in the case of in-
fection or radiation injury. Margins of resection should
not be compromised by the size of the resulting defect.
Adequate resection is the key to cure for each of these
conditions.
4. The ideal reconstruction will seal the pleural space, re-
store rigidity to the chest wall, protect underlying or-
gans, and be covered with well-vascularized soft tissue.
68 CHEST WALL RESECTIONS 715
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69
Thymectomy and Resection of
Mediastinal Masses
Felix G. Fernandez, MD and Daniel Kreisel, MD, PhD

INTRODUCTION Encapsulated or invasive thymomas

Thymic carcinoma
The mediastinum can be divided into separate anatomic
compartments, the anterior, middle or visceral, and pos-
terior mediastinum.1 Tumors requiring surgical attention OPERATIVE STEPS OF RADICAL
generally originate in the anterior and posterior compart- TRANSSTERNAL THYMECTOMY 4
ments in this three-compartment model. Common ante-
rior mediastinal tumors include thymic tumors, thyroid Step 1 Median sternotomy
tumors, lymphomas, and tumors of germ cell origin. Step 2 Dissection of thymus off pericardium and encir-
Thymic tumors are the most frequently seen among this cling in midline
group. Posterior mediastinal tumors are most often neu- Step 3 Dissection of thymus off right pleura and
rogenic in origin, arising from intercostal nerves, sympa- pericardium
thetic ganglia cells, or paraganglia cells. This chapter Step 4 Dissection of cervical extent of right thymic lobe
therefore examines complications of mediastinal surgery from carotid artery and strap muscles
in the context of thymectomy and resection of posterior Step 5 Left lateral and cervical thymic dissections
mediastinal neurogenic tumors. Step 6 Dissection of inferior thymus from phrenic nerve
to phrenic nerve
Step 7 Sternal closure
Thymectomy
Although it has not been evaluated prospectively, thymec- OPERATIVE STEPS OF
tomy has become standard therapy for myasthenia gravis TRANSCERVICAL THYMECTOMY 5
based on signicant retrospective data.2,3 Two major sur-
gical approaches for thymectomy have evolved, transster- Step 1 Low cervical incision and splitting and elevation
nal and transcervical thymectomies, with video-assisted of strap muscles in midline to expose thymus
thoracic surgery (VATS) resection of the thymus also a Step 2 Mobilization of superior poles of thymus and
viable alternative. All procedures allow for extracapsular ligation near inferior thyroid vein
resection of the thymus but vary in the extent of medias- Step 3 Thymic dissection continued inferiorly into tho-
tinal fat removed, which may contain ectopic foci of racic inlet
thymic tissue. Transcervical thymectomy has been shown Step 4 Thymic veins divided posteriorly
to be less morbid and costly than the transsternal approach. Step 5 Inferior thymic poles dissected along pleura
Controversy exists as to whether response rates are similar Step 6 Inferior thymic poles swept off pericardium
with each procedure. For thymomas or thymic carcino- Step 7 Cervical wound closure
mas, however, a transsternal approach is indicated. Major
indications for thymectomy include thymic hyperplasia OPERATIVE PROCEDURE
associated with myasthenia gravis, encapsulated or invasive
thymomas, and thymic carcinoma. Median Sternotomy
INDICATIONS Sternal Disruption and Mediastinitis
Consequence
Myasthenia gravis Sternal disruption impairs the respiratory mechanics of
Thymic hyperplasia the patient and may result in respiratory embarrassment
 718 SECTION XI: THORACIC SURGERY

requiring mechanical ventilation. Underlying mediasti- Prevention

nal infection may produce sepsis including fevers, Visualization of this thymic vessel is essential to prevent
rigors, and hypotension. The incidence of sternal dis- injury. As one dissects under the thymus from an
ruption is reported to be between 1% and 4%.3,6,7 inferior-to-superior direction, one must anticipate the
Grade 3/4 complication position of the brachiocephalic vein and look for the
thymic vein entering, typically, the inferior surface of
Repair
this vessel (Figs. 691 and 692). Typically, there are
If a sternal disruption with underlying mediastinitis is
two veins. The dissection should not stray from the
detected early, the wound may be dbrided and drained
surface of the pericardium. When using a transcervical
with primary sternal closure. For lateral weakness or
approach, the thymus is dissected off the anterior
fractures in the sternum, a lateral longitudinal wire
surface of the brachiocephalic vein and the thymic veins
support as described by Robicsek8 may be used. Muscle
transposition aps are generally the preferred option,
however, especially in the setting of extensive medias-
tinitis or sternal disruption.9 Brachiocephalic vein
Thymic vein divided
Prevention
Preoperative antibiotics covering typical skin ora
should be administered prior to skin incision. The
surgeon should ensure that the sternum is divided in
the midline. There is no evidence that the use of closed
suction drains reduces the incidence of mediastinitis or
sternal wound infections.

Dissection of the Thymus off the Pericardium

and Encircling in the Midline
Injury to the Thymic Veins or the
Brachiocephalic Vein
As the thymus is dissected off the pericardium in a caudal-
to-cephalad direction in order to encircle it with a tape,
the thymic vein draining thymic blood into the brachio-
cephalic vein is invariably encountered. This vein is typi-
cally located near the midline originating off the inferior
border of the brachiocephalic vein. Failure to recognize Figure 691 Dissection on the inferior border of the brachioce-
this vein or too vigorous retraction of the thymic tissue phalic vein reveals the thymic vein near the midline. This vein can
may result in injury to either the thymic or the brachio- be transected between ligatures. (Reproduced with permission
from Elsevier from Mason D. Radical transsternal thymectomy.
cephalic veins.
Oper Tech Thorac Cardiovasc Surg 2005;10:231243.)
Consequence
Injury to these veins results in bleeding with uncon-
trolled transection, which can be signicant if the bra-
chiocephalic vein is injured. If a transcervical approach
is used, a median sternotomy may be necessary to
provide exposure to control hemorrhage. Ligation of
the brachiocephalic vein may result in edema of the left
upper extremity, although reports indicate that the
edema will eventually resolve.10 If the pleural spaces are
open, blood may drain into a hemothorax. Thrombosis
of the subclavian vein has also been reported.11
Grade 1 complication
Repair
Thymic vein injuries may be simply ligated or over-
sewn. Injuries to the brachiocephalic vein may require
lateral venorrhaphy, end-to-end anastomosis, or liga-
tion. Tube thoracostomy may be required if a hemo-
thorax develops. Subclavian vein thrombosis must be Figure 692 Operative photograph demonstrates the thymic
treated with anticoagulation. vein ligated on the inferior border of the brachiocephalic vein.
 69 THYMECTOMY AND RESECTION OF MEDIASTINAL MASSES 719

are visualized and controlled posteriorly. Ventilatory

volume and rate may be reduced to facilitate exposure
of the mediastinum. Occasionally, the upper poles of
the thymus are located posterior to the innominate
vein, and this variant should be recognized.

Dissection of the Thymus off the Right Pleura

and the Pericardium
Phrenic Nerve Injury
As the thymus is dissected off the pleura and pericardium,
the phrenic nerve may be contused or divided. Phrenic
nerve injuries during thymectomies are reported to occur
in 0% to 4.5% of cases.6,7,12,13
Consequence
Injury to the phrenic nerve can result in paralysis of Figure 693 With the pleural reection opened, the phrenic
nerve is easily visible.
the ipsilateral diaphragm, which may be transient in the
setting of a neurapraxia or permanent if the nerve has
been transected. This may result in respiratory insuf-
ciency with prolonged mechanical ventilation, increased Vagus nerve
intensive care unit stay and development of respiratory
infections.14 Forced vital capacity has been shown to Aorta
be reduced after phrenic nerve injury.15 Spontaneous AP window thymoma
recovery of phrenic nerve function may be anticipated
in about two thirds of patients in whom the injury is Pulmonary artery
identied postoperatively.15 Most patients, however,
are asymptomatic.
Grade 1/2/3 complication
Repair
A primary repair of the phrenic nerve may be attempted, Phrenic nerve
but function is generally not restored. In cases of respi-
ratory impairment, transthoracic diaphragmatic plica-
tion to atten the diaphragm may be an effective means
of treatment.14
Figure 694 Extension of the thymus into the aortopulmonary
Prevention window. Thymic tumors may come in close proximity to or invade
The surgeon must visualize both phrenic nerves during the phrenic nerve in this location. (Reproduced with permission
dissection of the thymic lobes off of the pleura and from Elsevier from Mason D. Radical transsternal thymectomy.
pericardium. The phrenic nerves are less obvious in Oper Tech Thorac Cardiovasc Surg 2005;10:231243.)
the superior part of the mediastinum and thymus, and
adipose tissue must be dissected carefully without
excessive traction in this area to avoid injury. Dissection the aortopulmonary window, and this is the most
of the left side may be more challenging because the frequent site of phrenic nerve involvement (Fig. 694).
phrenic nerve may follow a more intimate course with A hemi-clamshell incision or left thoracoscopy may
the lateral portion of the thymus. The pleura may be improve exposure in these instances.
incised to facilitate visualization of the phrenic nerves
from within the thoracic cavities (Fig. 693). The
Recurrent Laryngeal Nerve Injury
pleura may be incorporated into the thymic specimen
if dense adhesions are present. Dissection with cautery Consequence
at low power in a patient who is free of muscle relaxants The incidence of damage to the recurrent laryngeal
should allow one to see or feel the diaphragm move, nerve is reported to be between 0% and 4.5%.6,7,12
indicating proximity to the phrenic nerve. The artery Injury to the recurrent laryngeal nerve results in ipsi-
accompanying the phrenic nerve provides some blood lateral vocal cord paralysis with the cord generally in an
supply to the thymus, and these small vessels should be abducted paramedian position preventing adequate
divided with hemoclips not cautery to avoid thermal airway sealing. Recurrent laryngeal nerve palsy may be
injury to the nerve. Thymomas occasionally extend into devastating in the early postoperative period owing to
 720 SECTION XI: THORACIC SURGERY

an inability to cough and clear secretions. Aspiration is

also a risk, especially in older patients. Long-term dis-
abilities may include hoarseness, shortness of breath,
swallowing difculties, and chronic aspiration. Older
patients and those with lung disease are less tolerant of
vocal cord paralysis. Patients with bilateral injuries can
potentially have compromise of their airway. Spontane-
ous recovery of nerve function is expected in the major-
ity of patients.
Grade 2/3/4 complication
Repair
None. Medialization of the paralyzed vocal cord with
autologous fat, Teon, gelatin, or collagen may be 3
attempted to palliate symptoms. These substances
create a rigid structure against which the normal vocal
cord apposes during cough, thereby sealing the
airway.16 2
Prevention
Surgeons should be aware of the intrathoracic anatomy
of the recurrent laryngeal nerves. The recurrent nerves 4
should never be handled directly or encircled for retrac-
tion purposes. A common site of injury during thymec-
tomy is in the subaortic region near the ligamentum
arteriosum. When thymic or mediastinal tumors are
1
present in the aortopulmonary window, a hemi-
clamshell incision or left thoracoscopy may be incorpo-
rated to improve exposure, as previously mentioned. In
addition, accessory thymic lobules may be present pos-
terior to the superior lobe of the thyroid, and the
recurrent laryngeal nerves must be identied and pre- Figure 695 The anatomic relationship of the cervical thymus
served when dissecting in this area6 (Fig. 695). and its variations and the recurrent laryngeal nerves (arrow).
Pneumothorax and Hydrothorax (1) Cervical portion of the left cervical-mediastinal lobe; (2) the
thymus superior to the brous cord, which may be continuous or
Opening of the pleural spaces during thymectomy may
discontinuous; (3) an accessory thymic lobule behind the superior
result in the accumulation of air or uid. The incidence
lobe of the thyroid; (4) an accessory lateral cervical thymic lobe.
of these complications ranges from 2% to 4.5%.11,12 (14, Reproduced with permission from Elsevier from Jaretzki A
Consequence 3rd, Wolff M. Maximal thymectomy for myasthenia gravis. Surgi-
The accumulation of air or uid in the pleural spaces cal anatomy and operative technique. J Thorac Cardiovasc Surg
1988;96:711716.)
can result in collapse of pulmonary parenchyma and
lead to impairments of ventilation and/or oxygenation.
In extreme cases, a tension pneumothorax may result.
Grade 2 complication Myasthenic Crisis
Myasthenic crisis is dened by the need for mechanical
Repair ventilatory support. The incidence of this complication
The large majority of small pneumothoraces will resolve after thymectomy for myasthenia gravis is reported to
on their own. Large pneumothoraces and hydrothora- range between 6% and 33%.13,17,18 Crisis is preceded by
ces should be evacuated with a thoracostomy tube. progressive weakness, oropharyngeal symptoms, refracto-
riness to anticholinergic medication, and intercurrent
Prevention infection in most patients. One study reported that risk of
As the thymic lobes are dissected off the right and left postoperative myasthenic crisis was affected by the pres-
pleural surfaces, entry into the pleural spaces is common. ence of preoperative bulbar symptoms, a previous history
If the pleural spaces have been entered, air may be of myasthenic crisis, antiacetylcholinesterase antibody
evacuated with a small rubber catheter prior to wound greater than 100 nmol/ml and intraoperative blood loss
closure. If, during the pleural dissection, the pulmonary greater than 1000 ml.19 Myasthenic crisis is a temporary
parenchyma has been injured producing an air leak, a exacerbation, and the goal is to keep the patient stable
chest tube should be left in that pleural cavity. until the transient stress of the surgery has passed and
 69 THYMECTOMY AND RESECTION OF MEDIASTINAL MASSES 721

responsiveness to anticholinesterase medications returns. INDICATION

Aggressive pulmonary toilet and ambulation should be
initiated postoperatively. Some groups advocate withhold- Hourglass or dumbbell tumor of posterior mediastinum
ing anticholinesterase medications for 48 hours postop-
eratively to increase the sensitivity of the receptors to these
Resection of Intraspinal Component of Tumor
drugs.20
Grade 1 complication Operative steps of a single stage approach for resection of
an hourglass tumor of posterior mediastinum

Resection of Posterior Step 1 Prone or semi-lateral prone position

Step 2 Midline incision over spinous process of involved
Mediastinal Masses vertebrae
Step 3 Muscles and fascia elevated off spinous process
Step 4 Hemilaminectomy and foraminectomy at appro-
Complications of surgery in the posterior mediastinum are
priate level, tumor exposed and neurosurgically
best considered by examining the resection of hourglass
resected
tumors of the posterior mediastinum. An hourglass (or
Step 5 Rib overlying tumor resected subperiosteally
dumbbell) tumor refers to a tumor with both intraspinal
along with transverse process
and intrathoracic components connected by a narrow
Step 6 Intrathoracic portion of tumor generally resect-
waist traversing the bony intervertebral foramen. These
able through the costotransversectomy
tumors are most often neurogenic in origin. The complex-
Step 7 Appropriate neurovascular bundle ligated
ity of the bony, vascular, and neural anatomy in the
Step 8 Layered wound closure
posterior mediastinum complicates the removal of these
tumors. Figure 696 illustrates the proximity of these Operative steps for two stage resection of an hourglass
various structures in the posterior mediastinum. Surgery tumor of posterior mediastinum
for hourglass tumors requires entry into two anatomic
Step 1 Posterior neurosurgical resection of intraspinal
regions: the thorax and the spinal canal. Hourglass tumors
component of tumor as detailed above
can generally be resected through one of two approaches:
Step 2 Costotransversectomy avoided
a single-stage approach or a combined anteroposterior
Step 3 Separate posterolateral thoracotomy or video-
approach involving both a laminectomy and a thoracot-
assisted resection of intrathoracic portion of
omy. VATS is often substituted for thoracotomy for the
tumor performed
thoracic phase of the operation.

Spinal Cord Injury

Paralysis as a complication of resection of a posterior
mediastinal hourglass tumor is rare but devastating. Injury
Vertebral body to the spinal cord may occur in several different ways. The
Intercostal vessels spinal cord is typically supplied by a large nutritive vessel
Enlarged foramen in the lower thoracic spine, commonly known as the artery
Displaced Head of thoracic rib of Ademkiewicz.21 Ligation of this blood vessel may render
spinal cord the spinal cord ischemic, resulting in paralysis, as has been
Dumbbell-shaped
Intercostal neurogenic reported.22 Inadvertently cutting across the narrow foram-
nerve tumor inal tumor neck can result in tumor hemorrhage and
Pedicle
spinal cord compression. Finally, bleeding from the small
radicular arteries that originate from the posterior branches
of the intercostal arteries and supply the spinal cord
may also result in an epidural hematoma and cord
Facet compression.
Lamina
Transverse Intercostal
Spinous process nerves and Consequence
process vessels Injury to the spinal cord results in paralysis, with the
Figure 696 A large neurogenic hourglass tumor is demon- decit being variable depending on the level and extent
strated with a compressed spinal cord, enlarged intervertebral of injury to the cord.
foramen, and large posterior mediastinal tumor component. Note Grade 4 complication
the proximity of the surrounding structures. (Reproduced with
permission from Lippincott Williams & Wilkins from Kern JA, Prevention
Daniel TM. Resection of posterior mediastinal tumors. In Kaiser Proper imaging, typically with magnetic resonance
LR, Kron IL, Spray TL [eds]: Mastery of Cardiothoracic Surgery. (MRI), to determine whether a posterior mediastinal
Philadelphia: Lippincott-Raven, 1998; p 112.) tumor has an intraspinal component is essential to
 722 SECTION XI: THORACIC SURGERY
avoid inadvertent spinal cord injury from excessive
traction on the tumor or hemorrhage at the neural
foramina. Intraoperatively, involvement of the neural
foramina can be detected by the widening of the
foramen with visualization of the tumor entering along
the nerve root.23 Some groups advocate the use of
magnetic resonance angiography to identify the artery
of Adamkiewicz preoperatively because its position is
extremely variable.24 Finally, care should be taken in
identifying and controlling the small radicular arteries
originating from the intercostal vessels that supply the
spinal cord. These radicular vessels originate close to
the vertebral column; however, the presence of tumor
may signicantly distort the anatomy. Finally, absorb-
able gelatin sponges should not be left in the neural
foramina because they may swell and could compress
the cord.
Cerebrospinal Fluid Leak
Hourglass tumors may follow a nerve root intradurally. In
these circumstances, the dura must be opened and par-
tially resected in order to remove the tumor. The dura is
subsequently closed, and breakdown of this closure can
result in the development of CSF leak, generally draining
into the pleural space.
Consequence
The most signicant consequence of a CSF leak is
seeding of the dural space with bacteria and the devel-
opment of meningitis. A CSF leak may result in the
development of a pseudomeningocele in the thoracic
cavity.25 CSF leaks also decrease intradural pressure,
which may result in severe headaches.
Grade 2/3/4 complication
Repair
Signicant CSF leaks may be repaired in a variety of
manners, including pleural aps, pericardial fat, inter-
costal muscle, or a large piece of thrombin-soaked
gelatin sponge.21 Another treatment option is the inser-
tion of a lumbar drain to divert ow from the CSF
stula, allowing it to heal.26
Prevention
When the dura is violated, it should be closed meticu-
lously to avoid development of a stula. Some surgeons
have advocated covering the dural repair with brin
glue or some other biologic sealant.21 When the dura
cannot be closed primarily without tension, pleura,
pericardial fat, or intercostal muscle may be used to
bridge the gap. These options are also available to but-
tress a dural closure. Dural closure may be tested intra-
operatively with a Valsalva maneuver. If a patient is
believed to be at high risk for the development of a
CSF leak, a lumbar drain may be placed prophylacti-
cally. Excessive chest tube suction has also been impli-
cated in perpetuating CSF leaks, and placing chest
tubes to water-seal as soon as feasible is advocated.27
Resection of Intrathoracic Component of Tumor
Sympathetic Nerve Injury
The sympathetic chain is located on the heads of the ribs
from the thoracic inlet to the diaphragm. Neurogenic
tumors often arise from the sympathetic chain, and there-
fore, the resultant decit after resection of the tumor
cannot be considered a surgical complication but rather a
consequence of the operation. Injury to the sympathetic
ganglia is most frequently seen during thoracoscopic
sympathetectomy.
Consequence
Injury to the stellate ganglion results in Horners syn-
drome with the typical nding of ptosis, miosis, and
anhidrosis. Injury to the sympathetic chain below the
stellate ganglion may also produce signicant symp-
toms. These patients may experience hyperhydrosis,
tingling, and differences in skin color and temperature
in the affected areas.28
Grade 1 complication
Repair
Rarely, intercostal or sural nerve grafts have been used
with limited results to reverse Horners syndrome.29 A
blepharoplasty is generally performed for cosmetic pur-
poses, and the miosis can be treated with eyedrops.
Prevention
Often, sympathetic nerve injury is unavoidable because
the tumor may be originating from this structure.
However, one must be careful when dividing the sym-
pathetic chain at the appropriate level and use cautery
at low settings, especially when near the stellate
ganglia.
Injury to the Thoracic Nerve Roots
Consequence
Injury to a thoracic nerve root generally results in little
discernible decit except for numbness in a dermatomal
distribution. The exception is injury to the T1 or T2
levels where injury can result in compromise of ipsilat-
eral hand function, resulting in an ulnar hand with
clawing of the fourth and fth digits due to lumbrical
muscle weakness.
Grade 1 complication
Repair
Interposition nerve grafts with the intercostal and other
nerves have been attempted for injuries affecting hand
function with mixed results.
Prevention
Surgeons should be aware of the thoracic nerve roots
exiting the intervertebral neural foramina. Sacrice of
 69 THYMECTOMY AND RESECTION OF MEDIASTINAL MASSES
a nerve root may be unavoidable if the tumor originates
from that particular nerve.
Thoracic Aortic Injury
Consequence
Injury to the thoracic aorta can result in life-threatening
hemorrhage.
Grade 5 complication
Repair
Emergent primary vascular repair.
Prevention
Neurogenic hourglass tumors commonly receive their
nutritive blood supply from the intercostal arteries or
radicular braches from the intercostal vessels. The prox-
imity of these small vessels to the thoracic aorta must
be recognized to avoid avulsing them off the aorta.
Anatomic distortion by the tumor may make these
small vessels originating from the aorta difcult to iden-
tify and place the aorta at risk for injury.
Esophageal Injury
Consequence
Transmural injury to the esophagus can result in leak
of esophageal contents with mediastinitis and/or
empyema. An esophageal leak in patients undergoing
resection of hourglass tumors may also result in men-
ingitis if the dura of the spinal cord has been violated
and a cerebrospinal uid (CSF) leak is present. Con-
tamination of the mediastinum will result in infection
that can become a diffuse necrotizing mediastinitis with
systemic sepsis and multisystem organ failure.
Grade 2/3/4 complication
Repair
Perforations of the esophagus may generally be repaired
primarily. The esophageal muscle is incised to visualize
the entire mucosal defect, and the tissue is dbrided to
healthy edges. The esophagus is then closed in two
layers. Vascularized tissue should be used to reinforce
the repair. Options include parietal pleural, intercostal
muscle, and pericardial fat pad. A nasogastric tube is
placed past the repair, and several chest tubes are left
in the thorax.
Prevention
Mobilization of the esophagus to access posterior
mediastinal tumors should be done away from the
esophagus to minimize the risk of injury or devascular-
ization if possible from an oncologic standpoint. Retrac-
tion of the esophagus should be performed gently,
either bluntly or by encircling it with a Penrose retrac-
tor. Aggressive grasping of the esophagus should be
avoided, as should the use of thermal energy in close
proximity to it.
723
Chylothorax
The thoracic duct enters the chest through the aortic
hiatus and is located to the right of the vertebral bodies
until it crosses to the left, typically at the level of T5 or
T6. The thoracic duct may be injured at any point along
its course in the posterior mediastinum.
Consequence
Presentation is typically delayed until the patient has
resumed oral intake. Chest x-rays will demonstrate a
rapid accumulation of a pleural effusion. The amount
of pleural drainage can be as high as 1.5 to 2 liters a
day. Patients may become hypovolemic from excessive
uid losses and develop signicant electrolyte abnor-
malities. Owing to the high protein content of chyle,
protein depletion occurs quickly, accompanied by
weight loss. Decreases in peripheral lymphocyte counts
also result in a state of immunosuppression.
Grade 2/3/4 complication
Repair
None. Intraoperatively recognized thoracic duct inju-
ries should be suture-ligated to prevent a leak. Chyle
leaks may be managed conservatively with chest tube
drainage, cessation of oral intake, and total parenteral
nutrition. In the setting of persistent high-output tho-
racic duct stulas or nutritional or metabolic complica-
tions, reoperation is necessary. Options include direct
ligation of the stula through reopening of the previous
incision. Heavy cream may be given to the patient
preoperatively to help in identication of the stula. A
second option is interruption of the thoracic duct above
the diaphragm.30 Interventional radiology techniques
may also be attempted to embolize the stula with
some reported success.31
Prevention
Thorough knowledge of the course of the thoracic duct
is essential when operating in the mediastinum. If
copious drainage of milky uid is encountered when
operating in the posterior mediastinum, injury to the
thoracic duct should be expected and aggressively
searched for.
Vagus Nerve Injury
Consequence
If only one vagus nerve is injured, there is generally no
consequence unless the injury occurs high in the medi-
astinum proximal to the origin of the recurrent laryn-
geal nerve, which would result in ipsilateral vocal cord
paralysis, as discussed previously. If both vagus nerves
are injured, gastrointestinal complications may result,
namely, delayed gastric emptying and postvagotomy
diarrhea.
Grade 1 complication
 724 SECTION XI: THORACIC SURGERY
Figure 697 The azygos vein is being divided over the thoracic
esophagus in the posterior mediastinum. Visible is an esophageal
leiomyoma within the esophageal wall, which was enucleated.
Repair
None. Medialization of the ipsilateral vocal cord is
required if the injury occurs proximal to the origin of
the recurrent laryngeal nerve.
Prevention
The surgeon must have an understanding of the medi-
astinal course of the vagus nerves. In particular, its
position high in the thorax should be appreciated in
order to avoid recurrent nerve palsy.
Azygos Vein Injury
Consequence
Signicant intraoperative hemorrhage may occur if the
azygos vein is inadvertently injured.
Grade 3 complication
Repair
Primary vascular repair or ligation.
Prevention
The surgeon must be aware that the venous outow of
a posterior mediastinal tumor may be in close proxim-
ity to or directly into the azygos vein (Fig. 697). In
addition, the tumor mass may distort the anatomy and
make this difcult to identify. The azygos vein can
usually be divided with impunity, and early ligation
of this vessel may protect it from injury and improve
exposure.
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14. Lemmer J, Stiller B, Heise G, et al. Postoperative phrenic
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16. Kraus DH, Ali MK, Ginsberg RJ, et al. Vocal cord
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17. Cohn HE, Solit RW, Schatz NJ, Schlezinger N. Surgical
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21. Shadmehr M, Gaissert H, Wain J, et al. The surgical
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 69 THYMECTOMY AND RESECTION OF MEDIASTINAL MASSES
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70
Esophageal Surgery
Angela M. Mislowsky, MD and
Richard F. Heitmiller, MD
INTRODUCTION
Esophagectomy is a complex surgery associated with sig-
nicant morbidity and mortality. Complications can lead
to lengthy hospital stay and can negatively affect postsur-
gical quality of life by altering or interrupting the ability
to swallow. Understanding the complications that are pos-
sible with this surgery is vital to their prevention. The two
key principles for performing esophagectomy successfully
are (1) to prevent complications to begin with, if possible,
and (2) to have safeguards in place to manage complica-
tions if they do occur. The objective of this chapter is to
review both principles.
INDICATIONS
Esophageal cancer
Barretts mucosa with high-grade epithelial dysplasia
Advanced functional disorders
Multiple failed previous antireux procedures
Strictures
OPERATIVE STEPS
Step 1 Positioning: supine with head turned to right
Step 2 Incision: supraumbilical incision from xyphoid
to umbilicus
Step 3 Divide triangular ligament and retraction of left
lateral segment of liver
Step 4 Separate greater omentum from stomach
Step 5 Divide short gastric vessels
Step 6 Incise peritoneum overlying hiatus, encircle
esophagogastric junction
Step 7 Divide gastrohepatic omentum
Step 8 Divide left gastric vessels
Step 9 Mobilize distal greater curve of stomach
Step 10 Perform Kochers maneuver
Step 11 Perform pyloroplasty or pyloromyotomy
OPERATIVE PROCEDURE
The technique of esophagectomy can be broken down
into three parts, as summarized in Box 701. The rst is
the step of gastric mobilization; the second, esophageal
dissection along with at least single-eld lymphatic dissec-
tion for patients with cancer; and the third is the recon-
structive esophageal anastomosis. We have advocated
routine use of an adjuvant jejunostomy feeding tube.1
When used, this would be the fourth surgical step.
The several different incisional approaches to perform-
ing esophagectomy include transhiatal (midline laparot-
omy, left cervical incision), Ivor Lewis (right thoracotomy
and midline laparotomy), three-incision (cervical, right
thoracotomy, midline laparotomy), and left thoracoab-
dominal methods. Despite their widely variant incisions,
all utilize the three-part surgical steps stated previously.
Selection of the specic approach is based on location of
the esophageal tumor or disease, reconstruction plans, and
surgical preference. In experienced hands, there is no dif-
ference in morbidity, mortality, and survival as a function
of surgical approach.
The majority of surgeons prefer to use the mobilized
stomach to replace the resected esophagus. Advantages
of the stomach as a replacement conduit include easy
mobilization and superb blood supply that minimizes
the incidence of conduit ischemia and results in only
one anastomosis. Colon or jejunum may also be used as
replacement conduits. Doing so results in more operative
time, a higher risk of conduit ischemia, and more recon-
structive anastomosis. For the purposes of this chapter,
the discussion of complications largely focuses on the
technique of esophagectomy when the stomach is used
for esophageal replacement.
Complications
Complications are listed in the same order as they might
arise during the surgery and postoperative management
of a patient undergoing esophagectomy. Therefore, com-
plications include operative complications, those that
occur early and late during the initial hospital stay, and
 728 SECTION XI: THORACIC SURGERY

Box 701 Esophagectomy Technique: Overview Divide platysma and omohyoid

Retract sternocleidomastoid and carotid sheath later-
Step 1 Gastric mobilization. If jejunum or colon is used ally and larynx and trachea medially
instead of stomach, assess conduit options before Dissect esophagus posterior along prevertebral fascia
proceeding with esophageal resection
Incise areolar tissue overlying lateral esophageal wall
Step 2 Esophageal dissection
Dissect esophagus circumferentially
Step 3 Reconstructive anastomosis; most commonly,
esophagogastric anastomosis Continue circumferential mobilization of esophagus
Step 4 Adjuvant jejunostomy down to carina
Divide cervical esophagus and deliver into abdomen
with umbilical tape tied to esophagus to maintain
Box 702 Esophagectomy Complications posterior mediastinal route
Operative
Bleeding
Abdominal Phase Part II
Splenic injury Tubularize gastric conduit
Airway injury Bring gastric conduit through posterior mediastinal
Esophageal conduit issues tunnel and out cervical incision
Transmural opening
Esophagogastric anastomosis
Ischemia
Place cervical drain
Insufcient length
Chyle leak Feeding jejunostomy
Close incisions
Early Inpatient Complications (<72 hr)
Respiratory complications Surgical Resection of the Esophagus
Atelectasis
Pleural effusion
Operative Bleeding
Respiratory failure
The esophagus has a diverse and robust blood supply
Pneumonia and lies in close proximity to many prominent vascular
Hoarseness (recurrent laryngeal nerve injury) structures. Therefore, surgical resection of the esophagus
Conduit ischemia always carries a risk of signicant bleeding. The reported
Arrhythmia rate of perioperative hemorrhage complicating esopha-
gectomy ranges from 0.3% to 4%.24 The risk and conse-
Late Inpatient Complications (>72 hr) quences of bleeding vary depending on the technique of
Aspiration pneumonia esophagectomy. The risk of bleeding related to preparing
Anastomotic leak the stomach for esophageal conduit is shared by all inci-
Wound infection
sional techniques.
Chyle leak
Open thoracotomy approaches minimize the risk of
Postdischarge Complications unexpected vascular injury because these methods give
Anastomotic stricture direct visual exposure of the operative eld. In addition,
Diaphragmatic hernia vascular injuries can be promptly identied and repaired,
generally through the same exposure. Conversely, these
approaches add a thoracotomy incision and open the
nally those encountered after discharge. The complica- mediastinal pleura. Diffuse, small mediastinal bleeding
tions to be discussed are listed in Box 702. vessels, likely to thrombose if contained to the mediasti-
num, may result in greater blood loss if they can drain
into the opened pleural space. Risk of chest wall bleeding
Transhiatal Phase from the thoracotomy incision is also introduced.
Blunt dissection of esophagus away from surrounding Transhiatal esophagectomy is associated with very real
pleura and aorta with downward traction maintained and signicant bleeding during the intrathoracic, blunt,
on gastroesophageal junction or transhiatal phase of esophageal dissection. Bleeding may
Small vessels and lymphatics are clipped and divided result from large esophageal arteries originating from the
Dissection progresses cephalad, staying on esophagus aorta, inferior pulmonary vein, or pulmonary artery, as
Proximal small vessels and lymphatics are avulsed when illustrated in Figure 701. Bleeding is usually immediately
unable to clip apparent as brisk blood ow exiting from the lower medi-
astinum or from the neck. However, if the mediastinal
pleura has been opened during transhiatal dissection, then
Cervical Phase the bleeding event, or at least its severity, can be masked.
Oblique incision along anterior border of When this happens, the rst sign of trouble is an unex-
sternocleidomastoid pected volume requirement or unstable hemodynamics. It

Figure 701 The proximity of the esophagus to major intratho-
racic vascular structures such as the pulmonary artery, superior and
inferior pulmonary veins, aorta, and esophageal arteries and the
juxtaposition of the airway and esophagus.
is essential that the surgeon and anesthesiologist remain
in communication during this phase of the operation.
The abdominal phase of esophagectomy involves mobi-
lizing the stomach based on the right gastroepiploic arcade
and adding a Kocher maneuver. Bleeding may occur from
any of the divided vessels including the short gastric, right
and left gastric, and paraduodenal vessels. Bleeding is
most likely to occur in regions where exposure is most
compromised. Most commonly, this means the short
gastric vessels and the left gastric vessels. Splenic injury is
discussed separately.
Consequence
The consequence of bleeding varies greatly depending
on the vessel injured, what esophagectomy technique
is being used, and how rapidly the problem is diag-
nosed and repaired. Outcomes range from bleeding
that increases the estimated blood loss but does not
require transfusion or change a patients clinical course
to exsanguination and death. From least to most severe,
consequences include
Bleeding from any vessel source that is controlled
but results in a need for transfusion.
70 ESOPHAGEAL SURGERY 729
Bleeding from any vessel source that requires re-
exploration for repair with or without transfusion.
Bleeding that is abnormal but self-limited. This may
result in hematoma or hemothorax with resultant
fevers, potential for infection, or respiratory
compromise.
Bleeding from the right gastroepiploic vessels whose
repair compromises the use of the stomach as a
replacement conduit.
Massive bleeding that jeopardizes the patients life,
may require additional incisions for exposure and
repair, and signicantly alters the patients planned
clinical care.
Grade 25 complication
Repair
For open surgical techniques, bleeding vessels are
directly exposed and bleeding is controlled by standard
methods. Smaller vessels are ligated or coagulated;
larger vessels may require proximal and distal control
prior to suture repair. Use of prosthetic material, such
as patches or pledgets, is to be avoided whenever pos-
sible because of the potential for infection from the
esophagus.
Intrathoracic bleeding during transhiatal surgery is
one of the most feared complications. Bleeding from
esophageal feeding arteries emanating from the aorta can
lead to a sizeable blood loss before it can be visualized
and controlled. If the vessel can be visualized easily in the
lower mediastinum, it should be ligated, clipped, or coag-
ulated promptly. If not, pack the mediastinum with a lap
pad. This will greatly reduce the bleeding and make
nding and controlling the vessel easier. Narrow hand-
held malleable retractors often help greatly to see up into
the mediastinum to nd the bleeding vessel. Liberal use
of suctioning and a surgeons headlight are also benecial.
Massive bleeding from the aorta, inferior pulmonary vein,
or pulmonary artery is immediately life-threatening. Once
bleeding is identied, it is essential that the surgeon have
an idea which vessel was injured. Even without seeing into
the chest, the surgeon should have an idea what was
injured based on where the dissection had been just before
injury. Pack the mediastinum. Notify your anesthesia col-
league. Get blood into the room. Consider calling for
vascular or cardiac surgery assistance. Almost invariably,
another incision will be needed to get exposure for repair.
A median sternotomy is not the best incision to use to x
the vessels injured during transhiatal dissection. A separate
thoracotomy is most appropriate. Choose left or right
based on what you think is injured. Rapidly close the
abdominal incision or leave it covered, turn the patient,
and get exposure. Then identify and control the bleeding
using standard methods. If the inferior pulmonary vein
is injured, it cannot simply be ligated because this will
destroy the lower lobe. In addition, an open pulmonary
vein risks serious air embolism. Position the patients head
down until the injury site is controlled. As mentioned
 730 SECTION XI: THORACIC SURGERY
previously, intraoperative consultation with cardiothoracic
surgery may be needed.
Prevention
Prevention is key to prevent bleeding complications.
For open cases, an understanding of the anatomy,
careful dissection, and prophylactic proximal and distal
control of vessels potentially at risk during esophageal
dissection or gastric mobilization will minimize bleed-
ing complications. Within the abdomen, use of mechan-
ical retraction devices, nasogastric decompression of
the stomach, and coagulating devices adapted from
laparoscopic surgery both optimize exposure and help
to safely coagulate and divide difcult exposure vessels
like the short gastrics.
During transhiatal dissection, the surgeon must stay in
the immediate paraesophageal plane, as shown in Figure
702. A nasogastric tube within the esophagus and down-
ward countertraction to keep the esophagus straight are
both very helpful. Alert your anesthesia colleague that
you are starting the chest dissection. Begin the dissection
posteriorly because this is often the easiest side of the
esophagus to clear. Never persist with transhiatal dissec-
tion if the pathology forces you off the juxtaesophageal
plane. If this is the case, convert to a thoracotomy
approach. It will make for a longer case but will prevent
disastrous consequences.
Penrose drain
encircles cervical
esophagus
Trachea
L. bronchus
Thoracic
esophagus
Hiatus
(enlarged
at midline)
Liver
Fundus
of stomach
Figure 702 Safe transhiatal esophageal dissection in the imme-
diate paraesophageal plane and the proximity of the trachea and
left main stem bronchus to the esophagus.
Splenic Injury
Injury to the spleen during esophagectomy requiring inci-
dental splenectomy occurs with a reported incidence of
4.1% to 8.4%.5,6 Most commonly, the spleen is injured by
traction on short gastric vessels during gastric mobiliza-
tion that secondarily tear the splenic capsule. Occasionally,
the spleen is directly injured by retraction. There are no
data to support routine inclusion of the spleen as part of
an esophageal resection for cancer. Although there are no
data that splenectomy inuences cancer recurrence rates,5
adverse consequences of splenectomy are well-described.
It is, therefore, a complication that should be avoided.
Consequence
Splenectomy increases a patients susceptibility to over-
whelming sepsis secondary to encapsulated organisms.
Grade 4 complication
Repair
The spleen is salvaged, if possible, using standard
methods of packing or suturing. If not, it is resected
keeping the dissection close to its hilum.
Prevention
Achieve optimal exposure of the upper abdomen using
assistants or mechanical devices for retraction. Keep the
stomach decompressed with a nasogastric tube. Avoid
unnecessary traction on the stomach and short gastric
vessels because this could result in secondary splenic
capsular tearing. Many coagulation or surgical clipping
devices originally designed for use in laparoscopy are
now in mainstream use with open surgeries. These
permit much easier control of the deep short gastric
vessels that were considerably more difcult to control
by standard ligation techniques.
Airway Injury
The trachea, carina, and main stem bronchi are in close
proximity to the esophagus and are at risk for injury
during esophageal resection (see Figs. 701 and 702).
The trachea is oriented so that its weakest feature, its soft
membranous wall, is immediately adjacent to the esopha-
gus. The defenses of the membranous wall are further
compromised when it is thinned and distended over an
indwelling endotracheal balloon cuff. The reported rate
of airway injury is unclear. Intraoperative injuries are iden-
tied and managed immediately. There is no reported
series to indicate rate of injuries.
The membranous wall of the trachea is at risk for injury
when encircling the esophagus in the neck during tran-
shiatal cases (Fig. 703). The trachea and carina are at risk
for injury while mobilizing proximal third esophageal
tumors in the chest. The main stem bronchus, especially
on the left side, is at risk for injury during transhiatal
esophageal dissection. If the airway opening is proximal
to the endotracheal tube (ETT) cuff, the surgeon will
see the open airway; however, there should be no change
in the patients cardiorespiratory status. If, however, the

Carotid
sheath
Thyroid Esophagus
Trachea
Recurrent
laryngeal n.
Figure 703 The membranous wall of the trachea is at risk for
injury during mobilization of the cervical esophagus.
airway is opened distal to the ETT cuff, air escapes during
positive-pressure ventilation leading to an urgently unsta-
ble situation.
Consequence
The consequence of the airway opening depends on
its orientation with regard to the endotracheal cuff. An
airway injury proximal to the balloon cuff merely opens
the airway. This can be repaired as described later. Both
the initial injury and the closure risk injuring the ipsi-
lateral recurrent laryngeal nerve (RLN). Failure to but-
tress the repair site with some tissue patch risks later
development of an esophagorespiratory stula.
An airway injury distal to the ETT cuff results in an
immediate escape of air and anesthetic gas, especially with
positive-pressure ventilation. Patients may become rapidly
unstable with limited ability to ventilate them and with
associated re risk if the electrocautery is used. During
transhiatal dissection, in addition to difculty with ventila-
tion, signicant pneumomediastinum and even tension
pneumothorax may result if there is communication with
the pleural space.
Grade 2/4/5 complication
Repair
Airway injury proximal to the ETT cuff should be
closed primarily with interrupted 4-0 Vicryl sutures.
The suture line needs to be secondarily covered with a
soft tissue patch such as a regional rotational muscle
ap, pericardial fat pad, or intercostal muscle pedicle
70 ESOPHAGEAL SURGERY 731
ap. The patients airway is then managed as per
routine postoperatively.
An airway injury distal to the ETT cuff requires more
urgent action. If the hole is accessible, it can be temporar-
ily occluded with ones nger. The best way to repair these
injuries, whenever possible, is to direct the ETT distal to
the hole to convert a distal airway hole into a proximal
one. If this cannot be done, have the anesthesiologist
manually ventilate the patient with more rapid, low-
volume breaths, then close the hole between breaths, as
described previously. This leaves the airway injury site
exposed to positive-pressure ventilation. In the short term,
this is acceptable; however, patients should be extubated
as early as possible postoperatively.
During transhiatal esophagectomy, if an airway injury
is created in the cervical trachea, it should be repaired
primarily. An intrathoracic injury requires repositioning
the patient for a thoracotomy. A right thoracotomy is
preferred. Not only will this provide exposure to the
trachea and carina, but the left posterior aspect of the left
mainstem bronchus is easily seen as well.
Prevention
Avoid blunt dissection methods when encircling the
esophagus. Doing so places the adjacent tracheal
membranous wall at risk for injury. When performing
transhiatal dissection of the esophagus, stay on the
esophageal wall.
Esophageal Replacement Conduit Complications
A healthy and properly functioning esophageal replace-
ment conduit is essential to a successful outcome after
esophagectomy. Many of the complications regarding
conduit use can be prevented during the operative proce-
dure. This section refers specically to the use of stomach
as a replacement conduit. However, the principles involved
could be applied to the use of colon or jejunal conduits.
The incidence of conduit ischemia for stomach, colon,
and jejunal grafts is 3.2%, 5.1%, and 4.2%, respectively.7
Three specic gastric conduit complications are dis-
cussedgastrotomy, ischemia, and insufcient length.
Gastrotomy results either from preoperative feeding tube
placement or from intraoperative injury. Ischemia is largely
an iatrogenic complication related to the technique of
gastric mobilization. The stomach is a versatile esophageal
replacement conduit that, once fully mobilized, should
reach to the neck. There are times during transhiatal
esophagectomy when this is difcult without excessive
tension.
Consequence
When stomach is used as a replacement conduit, it
functionally becomes the new esophagus. Therefore,
postoperative leakage from the stomach is as deadly a
complication as a primary esophageal leak. A virulent
mediastinitis develops that drains into the pleural
space if the mediastinal pleura has been opened at
surgery. Systemic sepsis rapidly develops with the
 732 SECTION XI: THORACIC SURGERY

potential for hemodynamic instability, multisystem

failure, and death.
A good clinical outcome after esophagectomy is greatly
dependent on the viability and function of the esophageal
replacement conduit. Nonnecrotic ischemia of the stomach Optional collar incision
is believed to increase the risk of both anastomotic leak
and stricture formation. If the stomach becomes frankly
necrotic, it must be emergently removed, the cervical
esophagus is diverted, the patient is unable to eat or drink
by mouth, and further surgery is needed in the future to
complete the esophageal reconstruction.
When the stomach conduit does not reach to the neck
during transhiatal esophagectomy, the temptation is to try
to pull the stomach tip more forcefully to get it to reach.
Doing so can result in progressive tearing of the fundus
tip or ischemia of the fundus secondary to disruption of
ne submucosal vascular arcades. Both circumstances may Angle of Louis
render the stomach graft unusable.
Grade 3/4/5 complication
Repair
All seromuscular stomach wall injuries should be closed
with ne silk Lembert sutures. Gastrotomies need to Figure 704 If the stomach conduit will not easily reach to the
be closed in two layers. neck during transhiatal esophagectomy, extend the cervical incision
Conduit ischemia is largely iatrogenic. Prevention is inferiorly and divide the upper sternum. This permits a lower
essential. Details are discussed later. During the proce- esophageal anastomosis and widens the thoracic outlet. (Adapted
dure, the surgeon must determine whether the conduit is from Heitmiller RF, Heitmiller ES: Surgery for myasthenia gravis. In
viable or not. If it is not, there are no data to support the Franco KL, Putnam JB Jr [eds]: Advanced Therapy in Thoracic
Surgery, 2nd ed. Hamilton, London, Ontario: BC Decker, 2005;
use of medication (such as steroids) or anticoagulation to
p 413.)
salvage the ischemic conduit. Nonviable conduits need
to be resected and another conduit chosen.
A properly mobilized stomach tube should reach to the
neck without tension. Preservation of the fundus, multiple
staple rings to create the stomach tube, and a generous
Kocher maneuver all contribute to optimal conduit length.
If the stomach still does not reach to the neck without
Level of cross section
tension, or because the thoracic outlet is too tight, two 1 Minimal post-op
options can handle this problem, illustrated in Figure Fundus divided compression of airway
704. 8 The rst is to extend the cervical incision onto the in 3 firings of 2
stapler
upper sternum in the midline to the angle of Louis. The 3
left cervical strap muscles are divided, thus opening
the thoracic outlet region and permitting a slightly lower Tr. Ao.
cervical anastomosis. The second approach is as listed
Gastric
previously plus adding a partial upper sternotomy. This tube
cervicomediastinal exposure greatly opens the thoracic
Figure 705 The stomach tube is fashioned by multiple rings
outlet and permits esophagogastric anastomosis several of a linear stapler. This optimizes stomach length. (Adapted from
centimeters lower than could be accomplished by standard Heitmiller RF. Impact of gastric tube diameter on upper mediastinal
cervical exposure. anatomy. Dis Esophagus 2000;13:288292, with permission.)
Prevention
It may not be possible to avoid gastrotomy. Use of
jejunostomy instead of gastrostomy feeding tubes pro- dence demonstrates that the width of the gastric tube,
tects the stomach but is not always possible. especially toward the fundus, is important to minimizing
The stomach is mobilized based on the right gastro- ischemic complications. A stomach tube measuring 4 to
epiploic arcade. There are no data demonstrating an addi- 5 cm in diameter seems to be the optimal width. A tube
tional benet to preserving the right gastric artery. Greater narrower than this will result in fundal tip necrosis; a
curvaturebased gastric tubes are fashioned by multiple gastric tube too wide risks ischemia and leakage along the
linear stapler application, as shown in Figure 705.9 Evi- lesser curvature staple line and is too bulky a conduit to

pass through the upper mediastinum. The blood supply
to the tip of the gastric tube comes from ne submucosal
vessels. Unnecessary traction on this portion of the
stomach tube will disrupt these ne vessels and risk fundal
tip ischemia.
Proper mobilization of the stomach with a Kocher
maneuver usually yields excellent length. When it does
not, extend the cervical incision inferiorly and proceed
with a lower reconstructive anastomosis.
Chyle Leak
Intraoperative chyle leak is usually only seen when using
right thoracotomy esophagectomy techniques. The tho-
racic duct may be injured anywhere along the intrathoracic
esophagus during its dissection from the mediastinum.
However, it is most prone to injury at the level of the
carina where the duct begins to cross from the right side
of the mediastinum to the left (Fig. 706).10 Identication
of a chylous leak may be difcult at times. Esophagectomy
patients often have trouble eating and have not eaten prior
to surgery. The chyle, therefore, may be low volume and
clear.
Subclavian vein
Superior
vena cava
Ribs
Azygos
vein
Aorta
Thoracic
duct
Diaphragm
Cisterna
chyli
Figure 706 The course of the thoracic duct from the abdomen
to the neck and its proximity to the azygos vein. The point at which
the duct moves from the right to the left side of the chest is
approximately at the level of the carina. (Adapted from Rodgers
BM. The thoracic duct and the management of chylothorax. In
Kaiser LR, Kron IL, Spray TL [eds]: Mastery of Cardiothoracic
Surgery. Philadelphia, New York: Lippincott-Raven, 1998; pp 212
220.)
70 ESOPHAGEAL SURGERY 733
Consequence
Failure to diagnose a signicant chyle leak leads to
postoperative chylothorax. This requires drainage,
delay in eating, nonenteric feeding, lengthened hospital
stay, and often, operative intervention for repair. Prior
to parenteral alimentation and recommendations for
early surgical repair for large leaks, the mortality of
this complication was signicant. It still is a serious
complication.
Grade 1 complication (if discovered and repaired at
surgery)
Repair
Postoperative chylothorax is discussed later under
Postdischarge Complications.
Prevention
It is often not feasible to prevent intraoperative tho-
racic duct injury. For patients with esophageal cancers,
complete resection with wide lymphatic dissection
supersedes thoracic duct protection. Whenever a right
thoracotomy approach is used for esophagectomy, it is
prudent to consider thoracic duct ligation as close to
the diaphragm as possible. This will prevent postop-
erative chylothorax.
Early Inpatient Complications (<72 Hr)
Respiratory Complications
Respiratory complications, including atelectasis, pleural
effusion, respiratory failure, and pneumonia, are both
some of the most common and some of the most serious
of the postoperative complications. At least some basilar
atelectasis and small pleural effusions are common after
esophagectomy. Gillinov and Heitmiller11 reported rates
of atelectasis and effusion of 97% and 85%, respectively.
Most of the time, this presents only as a radiographic
nding in a patient who is progressing as expected. Con-
versely, pneumonia leads to increased intensive care time,
lengthened hospital stays, and a greatly increased mortal-
ity. Many respiratory complications can be anticipated12
or even prevented with adequate preoperative medical
evaluation and risk assessment.13 Respiratory complica-
tions are discussed in order of their severity from least to
most serious. Atelectasis results from low lung volumes
associated with general anesthesia, incisional pain, and
bedrest. Pleural effusions are mostly transudates and result
from perioperative intravenous uid infusion especially in
the setting of poor nutrition status (low albumin). In
addition, there is the potential for transhiatal transit of
peritioneal uid into the chest after esophagectomy.
Consequence
Atelectasis is the collapse of alveoli in the dependent
portions of the lung associated with decreased lung
compliance, impairment of oxygenation, and increased
pulmonary vascular resistance. Radiographically, some
degree of basilar atelectasis is expected after esophagec-
 734 SECTION XI: THORACIC SURGERY
tomy. In its mildest form, patients develop fevers, a
cough, and perhaps, continued need for supplemental
oxygen. In its more severe form, or if left untreated, it
may progress to respiratory failure and pneumonia.14
Small, asymptomatic pleural effusions are commonly
identied on chest lms after esophagectomy and are of
little consequence. Larger effusions can lead to atelectasis,
increasing respiratory failure, and possibly, pneumonia.
Respiratory failure is more a consequence itself of atel-
ectasis, pleural effusion, pneumonia, or underlying respi-
ratory disease. However, once respiratory failure occurs,
it leads to prolonged intensive care and hospital stays.
Patients generally require prolonged invasive monitoring
with risk of line complications. Patients are immobile and
at increased risk for deep venous thrombosis and pulmo-
nary embolic episodes. Prolonged tracheal and esophageal
intubations increase the risk for tracheal injury and esoph-
agorespiratory stula formation. Oral feedings are delayed
pending extubation. Given that many patients present
with nutritional decits, a delay in enteral feeding (if adju-
vant jejunostomy has not been used) could ensue.
Pneumonia is one of the most severe postesophagec-
tomy complications and is associated with reported mor-
tality rates of 2.9% to 50%.11,12,1517 Pneumonia requires
antibiotic use, prolongs intensive care time, generally
lengthens overall hospital stay, and is associated with a
markedly increased chance of dying. Increased coughing
needed to clear pneumonia increases intrathoracic pres-
sure, jeopardizing the healing of the esophagogastric anas-
tomosis. Finally, because postesophagectomy pneumonias
are considered aspiration events, oral feedings are gener-
ally delayed until the pneumonia clinically resolves.
Grade 1/4/5 complication
Repair
Lung expansion maneuvers can help to expand col-
lapsed areas of the lung that can lead to the develop-
ment of atelectasis and pneumonia. These maneuvers
include incentive spirometry, chest physiotherapy, deep-
breathing exercises, postural changes, and coughing.11
The use of both bi-level positive airway pressure (BiPAP)
ventilation and nasotracheal suctioning must be avoided
or used with caution because they may potentially
injure the esophagogastric anastomosis and result in a
leak. If patients need airway suctioning, exible bron-
choscopy or reintubation should be considered.
The size of the pleural effusion dictates the treatment
regimen. Smaller effusions may be watched and managed
conservatively. Larger effusions, leading to symptoms and
lung compression, should be drained by thoracentesis or
chest catheter.18
Pneumonia is managed with antibiotics and respiratory
care per routine. Patients who need suctioning should
undergo bronchoscopy. If respiratory secretions are prom-
inent, consider reintubation for suctioning. Hold oral
feedings to minimize the likelihood of aspiration. Always
treat postesophagectomy pneumonia aggressively. It is
potentially life-threatening.
Prevention
As mentioned previously, some degree of basilar atel-
ectasis and small pleural effusions is a near certainty
after esophagectomy. With regards to atelectasis and
pneumonia, there are two postesophagectomy manage-
ment strategies. The rst believes that early (in the
operating room) extubation, optimal use of regional
anesthesia for pain control, and early patient mobiliza-
tion will reduce respiratory complications after esopha-
gectomy. The second strategy involves leaving patients
intubated at the end of the surgery and sending them
to the intensive care unit. Patients are extubated the
next day (or later, as clinical course dictates), once it is
clear that they are stable and chest lms are clear.11
Both strategies have their advocates. We believe that
the early postoperative period should focus on systemic
care and uid management while protecting the airway
from aspiration (with the ETT cuff), minimizing
secretions (with ETT suctioning), and atelectasis (with
positive-pressure ventilation). Preventing complica-
tions, especially respiratory ones, after esophagectomy
is key to a good outcome and short hospital stay.
Appropriate uid management will minimize the risk
of signicant pleural effusion. Many patients are taking
diuretics preoperatively. When appropriate, these should
be restarted after surgery. If a thoracotomy approach is
used, a chest drain is placed at surgery. This should be left
in place until approximately postoperative day 4 or 5. If a
transhiatal approach is used, care should be taken not to
open the pleural space. This will minimize the risk of
transhiatal passage of peritoneal uid.
Anticipate postoperative respiratory complications in
patients with cardiorespiratory risk factors such as asthma,
chronic obstructive pulmonary disease, and ischemic cor-
onary artery disease. Optimize the patients status before
surgery if possible.
Hoarseness (Ipsilateral RLN Injury)
The ipsilateral RLN is at risk for injury during upper
thoracic and especially cervical esophageal dissections.
The reported rate of RLN injury ranges from 9% to
16%.4,16,1921
Consequence
The consequence of RLN injury depends on the sever-
ity of the injury and the position of the affected vocal
fold. Hoarseness is the most common consequence of
RLN injury. Signicant hoarseness results in a very
breathy voice requiring a great deal of effort to com-
municate. Patients get winded quickly, which adds
further frustration to the recovery effort. The vocal fold
is one of the last and most effective defenses for airway
protection against aspiration. Studies have shown that
50% of patients with unilateral RLN injury have docu-
mented aspiration22,23 and are therefore at increased risk
for pneumonia.
Grade 3 complication

Figure 707 The anatomy of the recurrent laryngeal nerves.
Repair
Most affected RLNs are injured, not divided, and will
recover with time. Heitmiller and Jones23 showed that
patients prone to aspiration after transhiatal esophagec-
tomy will spontaneously recover airway protection sig-
nicantly or completely within 1 month after surgery.
During this time, enteral feeding via jejunostomy avoids
aspiration pneumonia. More severe decits may be
managed by vocal fold medialization transiently (by
injections) or permanently (by surgery).
Prevention
The risk of RLN injury can be minimized by an under-
standing of its anatomy (Fig. 707), careful dissection
around the nerve avoiding use of electrocautery, and
especially, avoiding traction on the nerve when encircl-
ing the cervical esophagus.18 Although the goal is zero
nerve injury, this is not always possible, especially in
cancer patients.
Conduit Ischemia
The success of esophagectomy is largely dependent on the
viability and function of the esophageal conduit. Often,
the risk of graft ischemia can be detected at surgery. Many
times, however, the operative procedure progresses well
and ischemic complications develop without warning.
Arterial insufciency will present early after surgery. The
rates of conduit ischemia have been listed previously. Any
patient early after surgery who is unstable without obvious
70 ESOPHAGEAL SURGERY 735
cause, who develops an elevated serum potassium,
signicant leukocytosis, or fever should be suspected of
having conduit ischemia. As bad as this complication is, it
is far worse to miss the diagnosis and let the patient
develop a possible intrathoracic esophageal leak.7
Consequence
Nonnecrotic cases present with high fever and leuko-
cytosis that ultimately resolves with supportive therapy.
Often, it is not clear what is wrong with the patient.
The clinical instability resolves spontaneously. Most of
the time, patients are systemically sick in a sepsis-like
state. Failure to make the diagnosis and treat patients
may result in multisystem failure, esophageal leakage,
esophagorespiratory or esophagovascular stula forma-
tion, and death.
Grade 3/4/5 complication
Repair
Prevention is the rule. There are no data to demonstrate
that treatment with steroids, anticoagulants, antibiot-
ics, or pressors will prevent the development of necrotic
ischemia once the process has started. If there is isch-
emia of the entire conduit, the patient must return to
the operating room for re-resection and esophageal
diversion (cervical esophagostomy and jejunostomy).
Reconstruction is planned as a second stage once the
patient has had the opportunity to recover fully.
Prevention
Prevention of ischemia by careful operative technique
is the best way to avoid ischemic complications. This
has been covered earlier in this chapter.
Arrhythmia
Cardiac arrhythmias, especially atrial brillation and supra-
ventricular tachycardia, can be a postoperative complica-
tion of esophagectomies. This is especially found in
patients who are over the age of 70 or have a history of
cardiac disease.24 Intraoperative risk factors include blood
loss and extensive thoracic dissection. The patients who
develop atrial brillation have a higher risk for other post-
operative complications. Aspiration, pneumonia, myocar-
dial infarction, anastomotic leak, and sepsis are the most
common.25
Consequence
The consequence of this complication is hemodynamic
instability, myocardial ischemia, and respiratory failure.
Long-term atrial arrhythmias may increase the possibil-
ity of systemic embolic episodes.
Grade 1 complication
Repair
The management involves conrmation of the diagno-
sis and standard arrhythmia treatment using medical or
electrical cardioversion. At this time, the patient should
undergo a full work-up to determine the underlying
cause of the arrhythmia.
 736 SECTION XI: THORACIC SURGERY
Prevention
Again, prevention lies in medically optimizing the
patient before surgery. A full cardiac work-up should
be performed if the patient has any history of cardiac
disease. Preoperative medications can be administered
as prophylaxis against postoperative atrial brillation.
These include digoxin, calcium channel blockers, -
blockers, and amiodarone. To date, no standard of care
has been developed to prevent atrial brillation in
esophagectomy patients.
Late Inpatient Complications (>72 Hr)
Aspiration (Pneumonia)
The risk of postesophagectomy aspiration and pneumonia
is not uniform. Patients are at greatest risk early after
surgery when they are sedated and supine and later when
they resume oral feedings.
Consequence
The consequence of aspiration is risk of pneumonia.
The signicance of this complication has previously
been covered. Just because a patient appears to be
progressing well toward discharge does not mean that
a life-threatening pneumonia cannot occur late in the
hospital course.
Grade 1/4/5 complication
Repair
The treatment has been previously discussed.
Prevention
Clinical evaluation of swallowing function is not sensi-
tive at identifying aspiration. The best way to screen
for aspiration is with contrast video esophagogram
studies.23 The consistency of the contrast can be altered
to mimic different foods. If signicant aspiration is
identied, oral feedings should be held, patients should
continue enteral jejunostomy feedings, should be dis-
charged home, and should undergo a repeat swallow-
ing study in approximately 4 weeks.
Anastomotic Leak
An esophageal anastomotic leak can be a potentially life-
threatening complication that may result in extended
mechanical ventilation, respiratory failure, or septic shock.
The reported leak rate for esophagogastric anastomosis
ranges from 0% to 14% in most series.16,20,21,2630 By
denition, scheduled plans to have a patient resume
swallowing are placed on hold. Most leaks occur around
postoperative day 4 or 5; however, leaks may occur earlier
or up to a week or two after surgery. If a leak is suspected,
the diagnosis is best conrmed by contrast esophago-
gram. If a patient is unable to swallow contrast, a tube
studycontrast infused through a nasogastric tubemay
be employed.
Consequence
The consequence of leak depends primarily on its
location. As mentioned previously, scheduled plans to
resume swallowing are placed on hold pending leak
management. A cervical leak, if suspected early and
managed, has the least adverse consequences. These
include a messy neck wound, usually some delay in
hospital discharge, a delay in swallowing, and an
increased risk of later anastomotic stricture formation.
An intrathoracic leak is a potentially life-threatening
problem. If the leak is large and drains into the medi-
astinum or pleural space, patients will rapidly develop
signs of systemic sepsis. Plans to resume swallowing are
on hold indenitely. Hospital stays are lengthened, and
the objective of therapy shifts to saving the patients
life without, if possible, jeopardizing the esophageal
reconstruction. This is not always possible.
Grade 3 complication
Repair
Cervical leaks are the easiest to manage. Neck wounds
must be widely opened to permit free transcervical
drainage. Neck wounds should be opened, viability of
the conduit conrmed, and the wound irrigated and
left open with packing.18 The better the drainage, the
faster the closure of the leak, and the less chance for
inferior extension of infection into the mediastinum. If
an adjuvant jejunostomy is in place, continue to advance
enteral feedings to goal. Once stable, patients may even
conclude treatment as outpatients. When cervical leaks
close, drainage from the wound abruptly ends and the
wound closes very fast.
Intrathoracic leaks are much more challenging.18 If the
leak is small and contained, it may be followed closely.
Keep the patient on nothing by mouth, use nasogastric
drainage if it is already in place, and advance enteral feed-
ings to goal. If it is not contained, the rst option is wide
drainage (nasogastric tube and chest drains) with intrave-
nous antibiotics and enteral feedings. Some patients will
weather this storm, but they will be sick, in intensive care,
with long hospital stays. The second option is to divert
the cervical esophagus, drain the chest and mediastinum,
and advance enteral feedings. The third option is to take
down the reconstructive conduit and divert the esopha-
gus. Obviously, this last option must be used if the conduit
is necrotic. With the last two options, reconstruction later
becomes a challenge.
Prevention
Prevention may not always be possible. Optimize
preoperative nutrition and cardiorespiratory function.
Avoid operating on patients who are catabolic or on
steroids.30 Carefully mobilize esophageal conduits to
avoid ischemia. Perform anastomosis carefully, without
tension. Secondarily reinforce anastomoses when pos-
sible.26 Consider esophagectomy approaches that use

neck anastomoses. Several reports indicate that leak
rates are affected by anastomotic technique.31
Wound Infection
Many esophagectomy patients have lost weight preopera-
tively, and the midline abdominal incision is potentially
exposed to contamination from the esophagus. As a result,
supercial wound infection is seen in approximately 5% to
10% of esophagectomy patients. The main bacterial con-
taminants are Staphylococcus aureus, coagulase-negative
Staphylococcus, Enterobacter species, Escherichia coli, and
group D Enterococcus.
Consequence
Wound infections, diagnosed early and treated, should
have little consequence. Patients may develop fever and
leukocytosis, which resolves quickly with treatment.
Antibiotics may be needed if cellulitis is present. Wound
packing will be required, but this should not delay
discharge or enteral feedings.
Grade 1/2 complication
Repair
An infected wound should be gently explored with
a sterile cotton swab and the loculations broken apart.
If the infection has not caused the fascial layers to
separate, the wound can be cleaned with sterile saline
followed by bedside dbridement of nonviable tissue
and packed with saline-moistened gauze to allow
healing by secondary intention from the base. A course
of antibiotics is needed only if there is associated
cellulitis.
Prevention
Optimized preoperative nutritional status, preoperative
antibiotics, intraoperative wound irrigation, and inter-
rupted wound closure will minimize the risk of abdom-
inal wound infection.
Chyle Leak
Chyle leakage secondary to thoracic duct injury has been
discussed previously. The reported rate of postesophagec-
tomy chlye leak is 3.7%; however, the risk of chlye leak
varies according to the location of esophageal disease. Rao
and coworkers32 reported rates of 0.8% for lower third
and 5.8% for middle third esophageal diseases. Although
sometimes suspected at surgery, chyle leakage is more
commonly seen around postoperative days 3 to 5 when
enteral feeding is started. At that time, the patient devel-
ops a large pleural effusion, usually on the right side but
it can occur on either side. If a chest drain is in place, the
characteristic high-volume, milky white drainage is noted.
Characteristic laboratory studies for chylous uid are listed
in Box 703. Prior to intravenous alimentation and current
strategies for early intervention, this complication was
associated with a high mortality.
70 ESOPHAGEAL SURGERY 737
Box 703 Appearance and Composition of Chyle
Appearance
Turbid, milky white
Layers upon standing into
Upper (chylomicrons)
Intermediate (milky)
Dependent (cellular)
Specic Gravity
1.0201.030
Protein Content
34 g/100 ml
Fat Content
14 g/100 ml
Triglycerides
>110 mg/dl
Consequence
Chyle is rich in protein, fat, and white blood cells.
Prolonged high-volume loss of chyle leads to nutri-
tional failure and immunosuppression. Wound healing
problems, anastomotic leakage, and infectious compli-
cations are all possible. Hospital stays are extended,
pending resolution of this problem.
Grade 2/3 complication
Repair
After diagnosis, enteral feedings are held to put the
gastrointestinal tract at rest and reduce chyle ow
through the thoracic duct. Intravenous feedings are
initiated. Treatment plans are largely based on chyle
drainage volume. Leaks less than 500 ml/day generally
resolve with drainage. Leaks with greater than 1000 ml/
day invariably need operative intervention for resolu-
tion. If drainage is high, a time period should be set
during which the leak should lessen quickly or opera-
tive intervention will proceed. Generally, this time
period is 5 to 7 days. If daily drainage is 500 to
1000 ml/day, it is hard to predict the clinical course.
Start with drainage and intravenous feedings, follow
output, and wait for 5 to 7 days to see the trend.
Operative repair involves low right thoracotomy or
thoracoscopy with thoracic duct ligation just above the
right hemidiaphragm (Fig. 708).10 Chylous leaks should
promptly resolve with surgery.
Prevention
Understanding thoracic duct anatomy during surgery
and prophylactically ligating the duct at surgery are the
best and only methods of prevention.
 738 SECTION XI: THORACIC SURGERY
Azygos
vein Lung (retracted)
Injured
thoracic duct
IVC
Aorta
Esophagus
(retracted)
Diaphragm
Figure 708 Operative ligation of the thoracic duct is performed
through the right chest. The thoracic duct is identied and ligated
low in the chest, close to the diaphragm. A right thoracotomy is
shown; however, the procedure could also be performed by tho-
racoscopy. (Adapted from Rodgers BM. The thoracic duct and the
management of chylothorax. In Kaiser LR, Kron IL, Spray TL [eds]:
Mastery of Cardiothoracic Surgery. Philadelphia, New York:
Lippincott-Raven, 1998; pp 212220.)
OTHER COMPLICATIONS
Additional specic complications associated with a
thoracoabdominal approach or Ivor Lewis approach to
esophagectomy are predominantly associated with the
thoracotomy incision.
Postdischarge Complications
Anastomotic Stricture
Anastomotic narrowing with healing may occur after
surgery. Most anastomotic strictures occur between 2 and
6 months after surgery. Risk factors for stricture include
location of anastomosis, conduit ischemia, early postop-
erative anastomotic leakage, preexisting low cardiac
output, and anastomotic technique. Factors believed to
be associated with a high risk of stricture include cervical
anastomosis, leakage, low preoperative cardiac output,
and hand-sewn anastomosis.30 Strictures may occur even
without these risk factors. Late anastomotic strictures
(>1 yr postoperative) must raise the suspicion of recur-
rent cancer.
Consequence
Signicant anastomotic narrowing results in poor
swallowing, reduced quality of life, reduced oral intake
with potential for weight loss, and increased risk of
overow aspiration.
Grade 1/2 complication
Repair
Progressive solid food dysphagia within 2 to 6 months
of esophagectomy, especially when a patients swallow-
ing was initially not restricted, is a sure sign of anasto-
motic narrowing. The diagnosis can be conrmed by
contrast esophagogram, but this is not always needed.
Flexible esophagoscopy will also make the diagnosis of
anastomotic stricture. It is essential that early endos-
copy be performed for later strictures to rule out recur-
rent tumor. Treatment is dilation. Our experience
has been that these are soft strictures that dilate easily
but have a tendency to recur unless they are dilated
slowly, in stages.26 Generally, two to three dilations
are needed to open the stricture in steps so that,
once open, it will stay open. Recurrence is then
uncommon.
Prevention
It may not be possible to prevent strictures. Careful
preoperative patient selection and preparation, mobili-
zation of the esophageal conduit without ischemia,
and creation of a tension-free anastomosis will help to
reduce the chance of stricture. Some data suggest that
avoiding neck anastomosis will reduce the incidence of
strictures. However, a cervical anastomosis prevents
the risk associated with leakagea much more serious
problem. Some believe that a stapled anastomosis
reduces stricture formation, whereas others have dem-
onstrated good results with hand-sewn methods.
Diaphragmatic Hernia/Paraesophageal Hernia
The esophageal hiatus is widened during esophagectomy
to permit passage of the replacement esophageal conduit
up into the chest. Postoperative herniation of abdominal
structures through the hiatus, alongside the conduit, has
been reported. This complication presents in two ways.
The rst is an acute presentation early in the postoperative
course. The second is as a late nding on surveillance
lms.33
Consequence
Early herniation is generally an acute event, with sig-
nicant herniation of transverse colon and omentum
into the right chest. It is associated with acute respira-
tory symptoms and requires operative repair. Late
herniation usually involves a section of the transverse
colon, is a radiographic nding, is asymptomatic, and
does not require intervention.
Grade 3 complication
Repair
Early herniation presents as an acute event with
prominent respiratory symptoms. Early transabdominal
exploration is indicated. The herniated contents are
reduced and the hiatus narrowed. Abdominopexy of
abdominal contents may sometimes be needed. Late
herniation is invariably an asymptomatic radiographic
nding and does not require intervention.

Prevention
At the initial surgery, open the hiatus only as much as
needed for intrathoracic dissection and passage of the
stomach conduit. If needed, narrow the hiatus anteri-
orly before closing the abdomen.
REFERENCES
1. Brock MV, Venbrux AC, Heitmiller RF. Percutaneous
replacement jejunostomy after esophagectomy. J Gastroin-
test Surg 2004;4:407411.
2. Matory YL, Burt M. Esophagogastrectomy: reoperation
for complications. J Surg Oncol 1993;54:2933.
3. Postlethwaite RW (ed). Surgery of the Esophagus, 2nd
ed. Norwalk, CT: Appleton-Century-Crofts, 1986; p 410.
4. Baue AE, Geha AS, Hammond GL, et al. Surgical options
for esophageal resection and reconstruction with stomach.
In Orringer MB (ed): Glenns Thoracic and Cardiovascu-
lar Surgery, 6th ed. Stamford, CT: Appleton & Lange,
1996; pp 899922.
5. Black E, Niamat J, et al. Unplanned splenectomy during
oesophagectomy does not affect survival. Eur J Cardiotho-
racic Surg 2006;29:244247.
6. Gockel I, Kneist W, Junginer T. Inuence of splenectomy
on perioperative morbidity and long-term survival after
esophagectomy in patients with esophageal carcinoma. Dis
Esophagus 2005;18:311315.
7. Wormuth J, Heitmiller RF. Esophageal conduit necrosis.
Thorac Surg Clin 2006;16:1122.
8. Heitmiller RF, Heitmiller ES. Surgery for myasthenia
gravis. In Franco KL, Putnam JB Jr (eds): Advanced
Therapy in Thoracic Surgery, 2nd ed. Hamilton, London,
Ontario: BC Decker, 2005; p 413.
9. Heitmiller RF. Impact of gastric tube diameter on upper
mediastinal anatomy. Dis Esophagus 2000;13:288292.
10. Rodgers BM. The thoracic duct and the management of
chylothorax. In Kaiser LR, Kron IL, Spray TL (eds):
Mastery of Cardiothoracic Surgery. Philadelphia, New
York: Lippincott-Raven, 1998, pp 212220.
11. Gillinov AM, Heitmiller RF. Strategies to reduce pulmo-
nary complications after transhiatal esophagectomy. Dis
Esophagus 1998;11:4347.
12. Law S, Wong KH, Kwok KF, et al. Predictive factors for
postoperative pulmonary complications and mortality after
esophagectomy for cancer. Ann Surg 2004;240:791800.
13. Arozullah AM, Conde MV, Lawrence VA. Preoperative
evaluation for postoperative pulmonary complications.
Med Clin North Am 2003;87:153173.
14. Duggan M, Kavanagh BP. Pulmonary atelectasis: a
pathogenic perioperative entity. Anesthesiology 2005;102:
838854.
15. Kita T, Mammoto T, Kishi Y. Fluid management and
postoperative respiratory disturbances in patients with
transthoracic esophagectomy for carcinoma. J Clin Anesth
2002;14:252256.
70 ESOPHAGEAL SURGERY 739
16. Orringer MB, Marshall B, Iannettoni MD. Transhiatal
esophagestomy: clinical experience and renements. Ann
Surg 1999;230:392400.
17. Avendano CE, Flume PA, et al. Pulmonary complications
after esophagectomy. Ann Thorac Surg 2002;73:922
926.
18. Lin J, Iannettoni MD. Transhiatal esophagectomy. Surg
Clin North Am 2005;85:593610.
19. Gockel I, Kneist W, Keilmann A, Junginger T. Recurrent
laryngeal nerve paralysis (RLNP) following esophagectomy
for carcinoma. Eur J Surg Oncol 2005;31:277281.
20. Katariya K, Harvey JC, Pina E, et al. Complications of
transhiatal esophagectomy. J Surg Oncol 1994;57:157
163.
21. Gandhi SK, Naunheim KS. Complications of transhiatal
esophagectomy. Chest Surg Clin North Am 1997;7:601
610.
22. Heitmiller RF, Tseng E, Jones B. Prevalence of aspiration
and laryngeal penetration in patients with unilateral vocal
fold motion impairment. Dysphagia 2000;15:184187.
23. Heitmiller RF, Jones B. Transient diminished airway
protection after transhiatal esophagectomy. Am J Surg
1991;162:442446.
24. Loran DB. Thoracic surgery in the elderly. J Am Coll
Surg 2004;199:773784.
25. Murthy SC. Atrial brillation after esophagectomy is
a marker for postoperative morbidity and mortality.
J Thorac Cardiovasc Surg 2003;126:11621167.
26. Heitmiller RF, Fischer A, Liddicoat JR. Cervical esopha-
gogastric anastomosis: results following esophagectomy for
carcinoma. Dis Esophagus 2000;12:264270.
27. Atkins BZ, Shah AS, et al. Reducing hospital morbidity
and mortality following esophagectomy. Ann Thorac Surg
2004;78:11701176.
28. Crestallano JA, Deschamps C, Cassivi SD, et al. Selective
management of intrathoracic anastomotic leak after
esophagectomy. J Thorac Cardiovasc Surg 2005;129:254
260.
29. Michlet P, DJourno XB, Roch A, et al. Perioperative risk
factors for anastomotic leakage after esophagectomy:
inuence of thoracic epidural anesthesia. Chest 2005;128:
34613466.
30. Briel JW. Prevalence and risk factors for ischemia, leak,
and stricture of esophageal anastomosis: gastric pull-up
versus colon interposition. J Am Coll Surg 2004;198:536
541.
31. Ercan S, Rice TW, Murthy SC, et al. Does esophagogas-
tric anastomotic technique inuence the outcome of
patients with esophageal cancer? J Thorac Cardiovasc Surg
2005;129:623631.
32. Rao DV, Chava SP, Sahni P, Chattopadhyay TK. Thoracic
duct injury during esophagectomy: 20 years experience at
a tertiary care center in a developing country. Dis
Esophagus 2004;17:141145.
33. Heitmiller RF, Gillinov AM, Jones B. Transhiatal hernia-
tion of colon after esophagectomy and gastric pull-up.
Ann Thorac Surg 1997;63:554556.
71
Cervical Tracheal Resection
and Reconstruction
Joseph B. Shrager, MD
INTRODUCTION
A wide variety of conditions cause anatomic or functional
narrowing of the trachea. The most efcient and effective
treatment for most of these conditions is tracheal resection
with subsequent end-to-end anastomosis (TR). Tech-
niques have been standardized since the 1960s to allow
these procedures to be performed with excellent results
and low morbidity and mortality. Release techniques have
been developed that frequently allow even long segments
to be resected with the creation of a tension-free anasto-
mosis that will usually heal without incident. However,
even in the most experienced hands, TR can engender a
variety of complicationssome of which are emergent
and life threatening.
This chapter reviews the basic operative steps of TR and
the complications that can be encountered as they relate
to each step. The management of each complication is
presented as well as technical details that can be followed
in order to try to prevent the complication from occurring.
I focus upon simple cervical tracheal resectionthe
excision of a segment of the upper trachea, not including
the cricoid cartilage or higher, carried out through a cur-
vilinear neck incision just above the jugular notch. More
complex resections including the larynx or the distal trachea
approaching the carina, though utilizing many of the same
basic principles, require somewhat different and more
advanced techniques that are beyond the scope of this
chapter. Further, it has been established that as the anasto-
motic level ascends, a progressive increase in complication
rate occurs: failure rates rise from 2.2% for trachea-trachea
anastomosis to 6.0% for trachea-cricoid anastomosis to
8.1% for tracheathyroid cartilage anatomosis.1
Two centers pioneered the techniques of TR that are
now in standard use around the world: these are the
groups formerly headed by Hermes Grillo at the Massa-
chusetts General Hospital (MGH) and by Grifth Pearson
at the Toronto General Hospital. Because I am more
familiar with the methods and results of the MGH group,
having trained with Grillo, I focus upon their techniques
and their published results in reporting the incidences of
the various complications.
INDICATION
Tracheal stenosis in upper third of trachea caused by
prior tracheostomy or endotracheal intubation, inam-
matory disorders, or tumors
OPERATIVE STEPS
Step 1 Rigid bronchoscopy with or without dilation
Step 2 Circumferential dissection of involved portion of
trachea
Step 3 Tension-releasing maneuvers
Step 4 Airway division
Step 5 Cross-table or high-frequency jet ventilation
(HFJV)
Step 6 Anastomosis
Step 7 Chin stitch
Step 8 Extubation
OPERATIVE PROCEDURE
AND COMPLICATIONS
Rigid Bronchoscopy with or without Dilation
Rigid bronchoscopy is nearly always performed immedi-
ately prior to TR for a variety of reasons. First, the view
of the mucosa with a Hopkins lens system passed via a
rigid bronchoscope is superior to that obtained through
a exible bronchoscope, therefore, decisions regarding
whether acute inammation has resolved and whether or
not there is any need to delay the procedure can be made
most accurately. Second, measurements of the length of
the stenosis, the distance from the distal end of the ste-
nosis to the carina, and the distance from the proximal
edge of the stenosis to the vocal cords can be made most
accurately with a rigid scope.
The most important reason for carrying out rigid bron-
choscopy immediately preoperatively, however, is the fre-
quent need for tracheal dilation immediately prior to the
procedure. One would like to pass at least a size-5 and
preferably a size-6 endotracheal tube (ETT) beyond the
 742 SECTION XI: THORACIC SURGERY
Figure 711 Bronchoscopic view of a postintubation tracheal
stenosis just prior to dilation with the rigid bronchoscope through
which the stenosis is seen. Dilation is performed to allow placement
of an endotracheal tube (ETT) prior to resection. It is done by
stretching the stenosis with serially larger rigid bronchoscopes.
stenosis prior to positioning and operation so that the
airway is secure and the dissection can proceed without
undue haste up to the point of initial airway division. In
situations in which a size-6 tube cannot be passed because
of the tight nature of the stenosis, progressive dilation
with rigid scopes will generally allow passage of such a
tube.
The technique of dilation involves beginning with a
scope with a diameter only slightly larger than the visible
tracheal lumen (Fig. 711). This bronchoscope is passed
through the stenosis and deeply into the airway, and it is
held there for at least 1 minute as the stenosis is stretched,
maintaining ventilation through the bronchoscope. A
scope that is 0.5 to 1 mm larger is passed next, and the
procedure is repeated until the lumen is sufciently large
to pass the ETT. For a critically tight stenosis, one can
use Jackson dilators passed through the bronchoscope
initially until the lumen is large enough to pass the tip of
the scope itself.
Preoperative Loss of Airway
Consequence
If not rapidly salvaged, this complication can lead to
death. Its occurrence requires the rapid and focused
application of all of the knowledge and abilities of
a team consisting of surgeon, anesthesiologist, and
nurses. Often, tracheostomy is necessary, complicating
the eventual TR. Patients who are salvaged may suffer
varying degrees of anoxic brain injury.
Grade 25 complication
Repair
The onus is clearly upon the surgeon to reestablish an
airway. If edema at the site of stenosis and prior dilation
is the cause of the loss of airway, a single attempt to
reintroduce a smaller rigid bronchoscope is the initial
maneuver. One can then ventilate via this scope as a
more detailed plan is formulated. If one is unable to
pass the scope into the trachea because of an unusually
large epiglottis or other supraglottic abnormalities,
visualization of the cords with use of a Miller blade on
the laryngoscope may be useful, followed by passage of
the rigid bronchoscope through cords that have been
directly visualized in this manner.
If the patient is persistently desaturated to less than 75%
and an airway cannot be reestablished from above, emer-
gent tracheostomy is necessary. Typically a size-6 trache-
ostomy is selected. The opening in the trachea is made
directly through the area of stenosis, if at all possible. This
will preserve the length of remaining healthy trachea and
will not increase the length of the ultimate tracheal resec-
tion that will be required. If, for some reason, an actual
tracheostomy cannot be performed or if it cannot be per-
formed expeditiously, and if HFJV is available, a needle
may be passed into the airway through or below the ste-
nosis and HFJV instituted.
Prevention
A surgical set sufcient to perform tracheostomy must
always be fully opened before the performance of rigid
bronchoscopy with dilation, and a variety of endotra-
cheal and tracheostomy tubes must be immediately
available should they be needed. Ideally, HFJV will also
be available. The surgeon and anesthesiologist need to
discuss in detail before the induction of anesthesia the
anesthetic and bronchoscopy plan, the likelihood of an
untoward event, and the plan in case of an untoward
event.
During dilation, one should hyperventilate and super-
oxygenate the patient through the scope each time a
scope is passed beyond the stenosis. This will allow a
greater period of time to pass the next larger scope before
desaturation or hypercarbia ensues. One should never
attempt to pass a exible bronchoscope, which does not
allow ventilation through a tight stenosisparticularly
not outside of an operating room where rigid scopes,
ETTs, and tracheostomies are available. This may pre-
cipitate airway occlusion without the ability to salvage the
situation.
Circumferential Dissection of the Involved
Portion of the Trachea
After the curvilinear cervical skin incision has been made,
subplatysmal aps are mobilized down to the jugular
 71 CERVICAL TRACHEAL RESECTION AND RECONSTRUCTION
Figure 712 Typically, one rst dissects the trachea circumfer-
entially only at the distal end of the diseased area. A Penrose
or red rubber drain is then passed around the trachea in this
location.
notch and up to the thyroid cartilage, and the anterior
wall of the trachea is exposed by division of the thyroid
isthmus. The critical portions of the operation are then
begun. In many cases, the distal extent of the internal
stenosis can be seen by thickening and scar tissue visible
on the external surface noted during mobilization. When
this line is unclear, a exible bronchoscope can be intro-
duced from above, and its light or visualization of a needle
passed into the lumen from without can be used to dem-
onstrate the distal extent to the operating surgeon. A ne
suture is placed on the external tracheal surface at this level
to indicate the extent of mobilization required and the
ultimate point of distal division.
The involved region of trachea is then mobilized rst
from its lateral, vascular attachments, then from the pos-
terolaterally placed recurrent laryngeal nerves, and nally
from the esophagus, which is closely apposed to the pos-
terior, membranous tracheal wall. A Penrose or red rubber
drain can then be placed around the trachea (Fig. 712).
Almost all of the circumferential dissection is carried out
sharply. In some cases, when there is little scarring or
inammation, circumferential dissection of virtually the
entire involved segment can be done prior to airway divi-
sion. In most situations, however, I mobilize only the
most distal portion of the involved airway circumferen-
tially, leaving the posterior dissection of the more proxi-
mal portion from the underlying esophagus for after the
division of the airway distally. After this distal division has
been carried out, the proximal segment to be resected can
be progressively lifted up, facilitating its dissection away
from the nerves and esophagus (Fig. 713). It is critical
that circumferential dissection be taken only about 5 mm
beyond what will become the margins of resection in
order to maximally preserve blood supply to the anasto-
mosis (see the section on Anastomosis, later).
743
Figure 713 After placing distal, midlateral stay sutures of 0-0
Vicryl and withdrawing the ETT, sharp division is carried out with
a scalpel. From this point on, cross-table ventilation is carried out.
Next, the proximal involved segment of trachea is dissected more
proximally away from the esophagus and recurrent nerves until the
proximal point of division is reached. (From Grillo HC. Surgery of
the Trachea and Bronchi. United States, BC Decker, Inc; 2004.)
Recurrent Nerve Injury
Consequence
Injury to one recurrent laryngeal nerve will cause hoarse-
ness, but it may also cause incomplete airway compro-
mise and swallowing dysfunction that can lead to
aspiration. A nerve is sometimes injured or stretched
but not actually divided; in this case, its function may
return over several weeks. In addition, the opposite
vocal cord may adapt over time, coming across the
midline to improve voice and prevent aspiration.
However, function will not be restored in the case of
complete division. If a nerve becomes paralyzed in a
medial position, it may serve as an obstruction to airow
but aspiration is less likely. If it becomes paralyzed in a
lateral position, it will not obstruct airow, but voice
will be weak and coughing difcult. Further, with a
cord in the lateral position, aspiration is more likely.
Injury to both recurrent laryngeal nerves usually creates
an airway emergency, with the patient being unable to
spontaneously ventilate adequately after extubation. This
will require urgent placement of a tracheostomy if one has
not been placed prophylactically after TR. It will also
typically cause severe aspiration difculties requiring the
establishment of long-term enteral feeding.
Out of a total of 521 TRs for postintubation stenosis
reported by the MGH group since 1986, 25 patients (5%)
had varying degrees of postoperative laryngeal dysfunc-
 744 SECTION XI: THORACIC SURGERY
tion.13 This included 62 patients who required complete
resection of the anterior cricoid (higher than a simple
TR). The laryngeal dysfunction was considered minor or
temporary in 14, but 11 patients had more severe dysfunc-
tion. Of these, 7 required tracheostomy (3 permanent),
1 required a permanent T-tube, and 1 required a subglot-
tic stent. Two patients required tube feedings for persis-
tent aspiration.
TRs for tumors of the upper trachea, as one might
expect given the greater extent of lateral dissection often
required to allow complete tumor excision, likely lead to
a greater incidence of recurrent nerve injury and laryngeal
dysfunction. The MGH group reported 26 cervical TRs
for tumor in a series of 126 primary tracheal tumors
reported in 1990.4 Among the 126, 11 (8.7%) suffered
vocal cord paralysis. Six (4.7%) suffered aspiration. Because
this number includes patients who underwent more exten-
sive resections and even carinal resections, the incidences
of these complications after simple cervical TR for tumor
are difcult to glean, but I believe it is fair to say that
resections for tumor have a higher rate of nerve injury
than those for postintubation lesions.
Grade 24 complication
Repair
Bilateral recurrent nerve injury requires emergent tra-
cheostomy and will almost certainly require prolonged
enteral feeding owing to chronic aspiration. Unilateral
recurrent nerve injury, if it is not associated with sig-
nicant aspiration and if the patient has an adequate
airway, can generally be monitored for improvement
over approximately 6 months. If, after that period of
time, an acceptable voice has not returned owing to a
persistently lateralized cord, that cord can be medial-
Right vagus nerve
Left common carotid
Right subclavian
artery
artery
Left subclavian
artery
Right recurrent
laryngeal nerve Right common
carotid artery
Right and left
brachiocephalic Left vagus nerve
veins
Aorta
Brachiocephalic
artery
Superior
Left recurrent
vena cava
laryngeal nerve
Pulmonary trunk
ized by a minor procedure performed by an experi-
enced otorhinolaryngologist.
If a unilateral recurrent nerve injury is associated in
the early postoperative period with aspiration and/or dif-
culty generating a sufciently strong cough owing to lack
of cord apposition, medialization can be performed early.
If aspiration persists, enteral feeds must be begun, but this
is almost always a temporary necessity in unilateral nerve
injury.
Prevention
Careful operative technique minimizes the risks of
recurrent nerve injury. When circumferentially dissect-
ing the trachea, one should not try to identify the
recurrent nerves. Rather, one hopes not to see them
whatsoever. The dissection is maintained directly on the
wall of the tracheal cartilage at all times. If this rule is
adhered to, only very rarely (e.g., in cases which a vig-
orous inammatory process has destroyed that cartilage
and/or drawn the nerve into a matted mass of inam-
matory tissue) that a nerve will be injured. If the wall
of the trachea is not clearly visualized, it is far better to
cut into what will ultimately be the resected specimen
while dissecting the trachea out than to try to stay
outside of it and risk injuring the nerve(s).
It must be understood by the tracheal surgeon that as
one more closely approaches the larynx, the recurrent
nerves (particularly on the right) are increasingly at risk
because their position becomes progressively more medial
and closer to the trachea until they nally disappear behind
the posterior cricoid plate (Fig. 714). It is, therefore, at
the upper end of the dissection and during true subglottic
resections that one must be most careful to stay directly
on the trachea.
Figure 714 Demonstration of how the recurrent nerves
become closer to the trachea and, thus, are at greater risk of injury,
as the dissection ascends cephalad toward the larynx. (From Grillo
HC. Surgery of the Trachea and Bronchi. United States, BC Decker,
Inc; 2004.)
 71 CERVICAL TRACHEAL RESECTION AND RECONSTRUCTION
In addition, cautery should be used extremely judi-
ciously as one approaches the posterior one half of the
trachea. The best technique is simply not to use cautery
whatsoever in this region because the punctuate bleeders
that develop here almost always seal spontaneously.
However, if cautery is necessary, only the exact point of
bleeding should be cauterized, and the device should be
set on an extremely low setting, preferably using the
bipolar cautery.
Because nerve injury does occasionally occur, these
patients should always be begun initially on thickened
liquids rather than clear liquids by mouth because thick-
ened liquids are less easily aspirated. The initial feeding
should be carefully monitored for signs of aspiration. Only
after thickened liquids have been tolerated for about 2
days should clear liquids be attempted.
Esophageal Injury
Esophageal injury is very rare and often recognized intra-
operatively. It is most likely to occur either as one encircles
the trachea prior to distal tracheal division or as one pro-
ceeds with cephalad dissection of the membranous wall of
the trachea off of the underlying esophagus.
Consequence
If discovered and repaired immediately, as is usually the
case, a small injury to the esophagus rarely leads to any
postoperative problems. An undiscovered esophageal
injury, or a repair that breaks down, may lead to wound
infection and neck cellulitis or tracheoesophageal stula.
The latter results from development of a communica-
tion between the area of esophageal injury and the
membranous wall portion of the tracheal anastomosis.
Grade 14 complication
Repair
If discovered intraoperatively, the esophagus should
be closed in two layers, and a strap muscle should be
mobilized based upon its inferior vascular pedicle and
interposed between the esophagus and the posterior
portion of the tracheal anastomosis (Fig. 715). I prefer
to tack the muscle circumferentially onto the area of
injury prior to creating the tracheal anastomosis. An
esophageal injury that is discovered late postoperatively
is more problematic and involves complex management
options beyond the constraints of this chapter.
Prevention
Esophageal injury, like recurrent nerve injury, can gen-
erally be prevented by staying directly on the wall of
the trachea. This is somewhat more difcult on the
membranous than the cartilaginous wall because the
former is often less well dened. There have been cases
of resection of benign tracheal stenoses during which
I have left some of the posterior tracheal scar (remnant
of the membranous wall) in place on the esophagus in
order to avoid any possibility of creating an esophageal
745
Esophagus
Figure 715 Technique of mobilizing strap muscle for placement
between the esophagus and the trachea in the event of an esopha-
geal injury. The larger and more supercial of the strap muscles,
the sternohyoid, is divided at the upper end of the operative eld
and rotated into the space between the trachea and the esophagus.
It is tacked circumferentially around the injury with interrupted
horizontal mattress 00-00 Vicryl sutures taken into the esophageal
muscularis only. This type of muscle ap can also be used to isolate
the anastomosis from a tracheostomy tube on the rare occasion in
which a small tracheostomy is left in place at the completion of the
procedure. (From Reed MF, Mathisen DJ. Tracheoesophageal stula.
Chest Surg Clin North Am 2003;13:271290.)
injury. The technique mentioned previously of initially
mobilizing only the most distal portion of the involved
trachea circumferentially, then dividing at this level
before trying to dissect the trachea off of the esophagus
more proximally (see Fig. 713), is generally successful
at allowing safe dissection in this plane.
Tension-Releasing Maneuvers
Maximal reduction of tension on the tracheal anastomosis
is probably the most important single technical aspect of
these operations. The basic tension-releasing maneuvers
are preferably performed prior to airway division. In every
patient, the avascular, pretracheal plane is dissected all the
way down to the level of the carina to allow the distal
trachea to slide easily upward into the neck. In resections
of 4 cm or greater in length, a suprahyoid laryngeal release
(SLR) will often be required to create a tension-free anas-
tomosis; this can be performed at this point as well. Alter-
natively, one can save this last maneuver to be carried out
after one has carried out the resection. At that point, one
can test the anticipated tension on the anastomosis by
bringing the cut edges together as the neck is exed by
the anesthesiologists. If this demonstrates that tension will
 746 SECTION XI: THORACIC SURGERY
Figure 716 The longer, more caudal incision pictured here is
the primary incision through which the tracheal resection with
subsequent end-to-end anastomosis (TR) is carried out.The smaller,
more cephalad incision is at the level of the hyoid bone for perfor-
mance of suprahyoid laryngeal release. Through this incision, the
muscles attached to superior margin of the middle two thirds of
the hyoid are divided, and the bone itself is divided at either end
of this mobilized portion. This allows the larynx to descend toward
the trachea, providing signicant tension relief for more extensive
TRs. The image here is taken after the release has been performed.
The forceps are spread to denote the distance that the hyoid has
descended after the release.
be present, the SLR can be performed at that time (Fig.
716). It is highly unusual for release maneuvers other
than dissection in the pretracheal plane or SLR to be
required for a standard cervical tracheal resection. When
a more extensive tracheal resection that requires median
sternotomy is being performed, infrahilar pericardial
releases are often added.
In what also might be considered a tension-releasing
maneuver, a 0-0 polyglactin suture is placed in most cases
in a midlateral location on each side of the proximal and
distal tracheal segments. These sutures ultimately take
tension off of the anastomosis when they are tied to one
another prior to tying the actual anastomotic sutures,
which have a less deep and thus less strong bite of tissue
(see the section on Anastomosis, later).
Figure 717 With the traditional technique of distal intubation
with an ETT, seen here, intermittent removal of the ETT from the
distal airway is required to allow placement of the anastomotic
sutures. Note the silk suture that emerges from the proximal
segment. This has been sutured to the end of the withdrawn ETT
to ensure that it can be relocated distally just prior to completing
the anastomosis.
Anastomotic Dehiscence or Restenosis
See discussion under Anastomosis, later. The two most
important technical features in avoiding anastomotic com-
plications are creation of a tension-free anastomosis with
the release procedures described here and maintenance of
the blood supply to the anastomosis by limiting circum-
ferential dissection of the trachea to no more than 5 mm
beyond the limits of resection.
Grade 35 complication
Airway Division
The most distal end of the segment to be resected is
divided rst, and cross-table ventilation is instituted
through a second ETT (Fig. 717; see also Fig. 713) or
HFJV passed through the original ETT into the distal
trachea (Fig. 718). The entire tracheal segment to be
resected is then dissected circumferentially as proximally
as necessary. The proximal point of division is then created,
and the resected segment is removed from the operative
eld.
Cross-table or HFJV
Both cross-table and HFJV have their advocates. The
former has the advantage of being readily available, but it
requires frequent removal and replacement of the tube in
order to allow placement of the posterior wall of sutures.
This can lead to hypoxia or hypoventilation occasionally,
but it should not be a problem if it is appropriately
attended to. HFJV allows a better, continuous view of the
operative eld without frequent manipulations (see Fig.
718), but it may have a somewhat higher incidence of
 71 CERVICAL TRACHEAL RESECTION AND RECONSTRUCTION
Figure 718 The high-frequency jet ventilator cannula seen here
passing through the anastomosis from above allows placement of
all sutures without serially withdrawing and reinserting a distally
placed ETT.
hypoventilation and requires more careful monitoring by
the anesthesiology team.
Anastomosis
Many technical methods of anastomotic creation have
been described. Historically, interrupted silk or polyester
sutures were used, but this led to an unacceptably high
rate of granulation formation.1 Since then, high rates of
success have been reported with interrupted polyglactin,
running monolament absorbable or nonabsorbable
sutures, and combinations of these.
My preference is for the MGH technique of interrupted
00-00 polyglactin. The detailed MGH method involves
placing all of the sutures circumferentially beginning pos-
teriorly, prior to securing them down (Fig. 719). They
are then tied from front (cartilaginous wall) to back (mem-
branous wall) after having tied the midlateral 0-0 tension-
releasing sutures (Fig. 7110) to one another. Before
these sutures are tied, the inatable bag that has kept the
neck extended until this point in the case is now deated,
and the anesthesiologist exes the neck and then main-
tains this moderately exed position until the end of the
operation when the chin stitch can be placed.
747
Figure 719 The classic Massachusetts General Hospital (MGH)
anastomotic technique wherein all 00-00 polyglactin sutures are
placed prior to being tied down, with the knots situated on the
outside of the tracheal lumen. The sutures are placed approximately
4 mm apart and 4 mm deep into the cut tracheal margin. (From
Grillo HC. Surgery of the Trachea and Bronchi. United States, BC
Decker, Inc; 2004.)
With the MGH anastomotic technique, all knots are
placed on the outside of the lumen. However, in relatively
straightforward situations in which the lumen is of normal
caliber after resection of a short involved tracheal segment,
some have found that it is more convenient and appears
to be equally successful to place the posterior half of the
anastomotic sutures rst with the knots within the lumen.
These can then be tied without the use of midlateral stay
sutures after having tied down at least two of the most
posterior cartilaginous wall sutures in order to take off the
initial tension. The anterior wall sutures can then be placed
and tied last (Fig. 7111).
The two sides of thyroid isthmus can be reapproximated
to provide some soft tissue coverage to the anterior portion
of the anastomosis.
Anastomotic Granulation Formation
Consequence
Prior to the change from silk or Tevdek to polyglactin
suture at MGH in 1978, 23.6% of patients had this
problem.2 It leads to partial or, in rare cases, complete
airway obstruction at the level of the anastomosis.
Grade 24 complication
Repair
Granulations can generally be managed by broncho-
scopic removal either mechanically or with careful use
of the laser. The offending suture(s) should also be
removed. This may require repeated bronchoscopic
 748 SECTION XI: THORACIC SURGERY
Figure 7110 Midlateral stay sutures of 0-0 Vicryl are placed as shown here for the distal segment, in both the distal and the proximal
segments to be brought together. These are tied down to one another as the shoulder bag is deated and the neck exed, immediately
before tying the actual anastomotic sutures. This serves to take tension off of the anastomotic sutures. (From Grillo HC. Surgery of the
Trachea and Bronchi. United States, BC Decker, Inc; 2004.)
Figure 7111 An alternative anastomotic technique that can be
used in simpler cases, in which the posterior half of the anastomotic
sutures have at this point been placed and tied with the knots within
the lumen. The anterior half-sutures have been placed and are
about to be tied down.
dbridement. Local steroid injections may prevent
reformation of granulations. Severe cases may require
temporary or permanent T-tube placement or even
tracheostomy when the granulations cannot be
controlled.
Prevention
After 1978, when the suture material used at MGH
was changed to polyglactin, only 1.6% of patients
have had a problem with granulation tissue formed at
the site of anastomosis.2 Use of absorbable monola-
ment or even nonabsorbable monolament suture also
appears to virtually eliminate this problem. However,
because the MGH series are the largest and most den-
itive, I believe polyglactin to be the anastomotic suture
that is most proved to avoid the formation of granula-
tion tissue.
Anastomotic Dehiscence/Restenosis
Consequence
The failure rate after anastomosis for all postintubation
stenoses was 5.8% in the MGH series. However, for
simple lesions requiring only trachea-to-trachea anasto-
mosis, the failure rate was only 2.2%.2 A 2004 review
of all 901 patients who had undergone tracheal resec-
tion in all locations and for all types of lesions found
on multivariate analysis that reoperation (odds ratio
[OR] 3.03), diabetes (OR 3.32), greater than 4 cm
resection length (OR 2.01), laryngotracheal resection
(OR 1.80), age younger than 17 (OR 2.26), and need
for preoperative tracheostomy (OR 1.79) were signi-
cant predictors of anastomotic complications.5
Early, complete dehiscence may lead to airway obstruc-
tion and death and is an emergency that may require T-
tube placement6 or tracheostomy. Incomplete dehiscence
or partial separation may not be noted clinically early on
but may lead to healing with a cicatrizing circumferential
scar that leads to restenosis. Either complete or incom-
plete dehiscence may, in rare cases, result in tracheoin-
nominate stula (TIF) or even tracheoesophageal stula.
Seven of 29 patients in the MGH series with complete
dehiscence died of this complication. Two of the deaths
were due to TIF.
Grade 35 complication
Repair
If early dehiscence is suspected, the patient is taken
urgently back to the operating room for rapid and
careful bronchoscopic evaluation. If a correctable tech-
nical error (such as lack of a needed release procedure)
 71 CERVICAL TRACHEAL RESECTION AND RECONSTRUCTION 749

is suspected, reanastomosis with a protective size-4 tra-
cheostomy tube placed two rings below the anastomo-
sis or reanastomosis over a T-tube is reasonable.
Alternatives include T-tube placement6 alone or full-
sized tracheostomy placement alone.
Patients with TIF create among the most difcult surgi-
cal emergencies. The airway in this situation must be
secured by endotracheal intubation with a cuffed tube and
the patient taken emergently to the operating room. Via
a median sternotomy, the innominate artery must be
divided before exsanguination or drowning occurs, the
involved segment is resected, and the remaining ends of
the artery are covered with surrounding muscle. In patients
without major preexisting cerebrovascular disease, this will
not lead to stroke. However, if intraoperative electrocar-
diographic monitoring can be rapidly arranged, a vein graft
can be used for reinstitution of ow if signicant changes
are identied with clamping. The anastomosis can then be
managed as described in the preceding paragraph.
Late anastomotic stenosis that occurs during healing of
an ischemic or partially separated anastomosis will present
with the typical symptoms of upper tracheal stenosis:
dyspnea and stridor. The MGH group published a series
of 75 reoperations for tracheal stenosis occurring after an
initial failed attempt at resection.7 Complications occurred
in 39% of patients, but 79% had an outcome considered
to be good, and another 13.3% had an outcome con-
sidered to be satisfactory. The repair was unsuccessful
in only 5.3% of patients, and 2.6% died perioperatively.
Options other than reoperation again include T-tube6 or
tracheostomy.
Prevention
There are two critical technical issues that must be
attended to in order to prevent anastomotic failure:
(1) minimizing devascularization of the tissue to
be anastomosed and (2) creating a tension-free
anastomosis.
To minimize devascularization, it is critical to maintain
the blood supply to the tracheal segments to be anasto-
mosed by leaving their lateral tissue attachments intact
(Fig. 7112), because these contain the major blood
supply. The airways to be anastomosed should be mobi-
lized circumferentially for no more than 5 mm beyond the
cut margin, and the cut margin should be handled as little
as possible to avoid tissue injury. Because the anastomotic
sutures are placed 3 to 4 mm deep, 5 mm of mobilization
is sufcient.
To create a tension-free anastomosis, the tension-
releasing maneuvers utilized in TRs include

Coronal section of tracheal wall...

Anterior transverse
intercartilaginous artery

Lumen
Trachea Submucosal capillary plexus
Transverse
intercartilaginous
Lateral longitudinal artery
anastomosis

Primary
tracheal
artery
Posterior transverse
intercartilaginous artery
Pattern of
microvasculature
of mucosa

Tracheoesophageal
artery Muscular posterior
Primary esophageal Esophagus wall of trachea
artery Secondary tracheal
twig to posterior wall
Figure 7112 Demonstration of the lateral tissue pedicles that contain the main blood supply to the trachea and thus must be left intact
beyond 5 mm from the cut margin of the tracheal resection. Because the anterior, pretracheal plane is avascular, it is bluntly dissected as
far as possible into the mediastinum as part of the routine tension-relieving procedures. (From Salassa JR, Pearson BX, Payne WS. Gross
and microscopical blood supply of the trachea. Ann Thorac Surg 1977;24,100107.)
 750 SECTION XI: THORACIC SURGERY

1. Dissection of the pretracheal plane to the level of the

carina (described previously).
2. Suprahyoid laryngeal release (described previously).
3. 2-0 Vicryl lateral stay sutures tied to one another
prior to tying anastomotic sutures (described
previously).
4. Taking down the inatable bag beneath the shoulders
and using neck exion during the tying down of the
anastomotic sutures (described previously).
5. The chin stitch (described later).

Numbers 1, 3, 4, and 5 are used in essentially all TRs,

while SLR is used only for longer resections or when
tension is noted upon the initial attempt to bring the cut
margins toward one another. It is critical that the cut ends
of the airway come together easily and with no more than
minimal tension. If they do not, the anastomosis will not
heal soundly.
A third important point in avoiding anastomotic com-
plications is to be sure not to operate upon a trachea that
is in the acute phase of inammation. If, upon preopera-
tive bronchoscopy, the airway remains edematous or
erythematous, it is best to postpone surgery until this
inammation subsides, even if this requires temporary
stenting with a T-tube6 or even tracheostomy.
Finally, if a patient has been on chronic steroids, these
should be weaned preoperatively to as low a dose as pos-
sible, preferably to the point of having been stopped com-
pletely for a month or longer. Although preoperative
steroid use did not fall out as a signicant predictor in the
MGH multivariate analysis described previously,5 common
sense and experience dictate that weaning steroids is
prudent if feasible. It may also be useful to administer
vitamin A perioperatively in patients who remain on ste-
roids to mitigate the known effects of steroids upon
healing.
With regard specically to TIF, one means of avoiding
this is always keeping the dissection plane directly on the
trachea when separating the innominate artery from
the airway. This leaves some investing soft tissue around
the innominate artery that will generally prevent subse-
quent erosion. In situations in which there is reason to
think that this investing tissue is not present, a ap of strap
muscle should be interposed between the innominate and
the anastomosis.
Chin Stitch
Once the anastomosis has been completed and the wound
closed over a Jackson-Pratt drain, a size 2 suture of Tevdek
or polypropylene is placed between the submental skin
and the skin over the angle of Louis (Fig. 7113). It is
important to note that the neck is to be held in only
modest exion. The intention of the skin stitch is more to
prevent the patient from suddenly hyperextending and
Figure 7113 The chin stitch shown here is intended not to
maximally ex the neck but only to hold it in no more than 45 of
exion and, more importantly, prevent sudden extension. Note that
this patient, who had a subglottic resection, has also had a small
tracheostomy placed below the anastomosis as a precaution.
thus stressing the anastomosis than it is to maintain dra-
matic exion.
Paraplegia
Consequence
Several case reports8 have described disastrous spinal
infarcts believed to have resulted from severe neck
exion after TR. I am aware of one other unreported
case of this terrible complication.
Grade 4/5 complication
Repair
If lower extremity weakness is noted, the chin stitch
should be immediately cut and the patient allowed to
return his or her neck to a neutral position. Elevation
of blood pressure to increase spinal perfusion might be
helpful.
Prevention
The neck should generally be exed to more than 45.
In the rare situation in which more than 45 of exion
is required to create a tension-free anastomosis, careful
monitoring of neurological function should be carried
out and the previously described maneuvers carried out
urgently if any decits are noted.
 71 CERVICAL TRACHEAL RESECTION AND RECONSTRUCTION
Extubation
Extubation is performed immediately after TR in the
operating room, if at all possible. This is facilitated by
avoidance of paralytic agents in the anesthetic. Occasion-
ally, one is sufciently worried about the anastomosis that
one protects it by placing a small, size-5, uncuffed
tracheostomy two rings below the anastomosis. Another
alternative after difcult resections, high laryngotracheal
resections, or resections in children in whom a small
amount of edema can reduce the smaller lumen signi-
cantly is to maintain intubation for 2 to 3 days postop-
eratively as a rapidly tapering course of steroids is given
to reduce edema.
Postoperative Airway Edema
Consequence
Most TR patients have some degree of airway edema
postoperatively, either at the level of the vocal cords or
at the anastomosis itself. However, this generally
becomes a problem only in those patients with anasto-
moses in the subglottic region or in children with
smaller airways. In these patients, stridor may develop
12 to 48 hours postoperatively that was not present
immediately postoperatively.
Grade 13 complication
Repair
Symptomatic airway edema can usually be managed
with head elevation, racemic epinephrine nebulizers,
diuretics, and a rapidly tapering 24-hour cycle of ste-
roids, if this was not already instituted. Heliox is also a
useful adjunct because its use reduces the resistance to
ow in the airways.9 In rare cases, the patient must be
taken back to the operating room for placement of a
small tracheostomy below the anastomosis or for very
careful reintubation from above with an uncuffed
ETT.
Prevention
A rapidly tapering 24-hour cycle of steroids is appropri-
ate for those with subglottic resections, children, and
those in whom more than the usual amount of cord
trauma was believed to have occurred during intuba-
tion or rigid bronchoscopy. All TR patients should
have minimal uid replacement postoperatively and be
managed with the head of the bed elevated. For those
considered to be at highest risk, a small tracheostomy
751
placed at the time of surgery or a planned, 2- to 3-day
postoperative period of intubation with an uncuffed
ETT can be considered.
SUMMARY
With careful attention to the details of surgery and post-
operative management, cervical tracheal resection can be
performed with anastomotic failure rates as low as 2.2%
and all other complications together totaling less than 5%.
The incidence of complications rises, however, as the
proximal point of resection enters the larynx.
This chapter has reviewed the management and preven-
tion of all complications of tracheal resection that occur
in substantial numbers.
REFERENCES
1. Grillo HC, Zannini P, Michelassi F. Complications of
tracheal reconstruction: incidence, treatment and preven-
tion. J Thorac Cardiovasc Surg 1986;91:322328.
2. Grillo HC, Donahue DM, Mathisen DJ, et al. Post
intubation tracheal stenosis; treatment and results. J Thorac
Cardiovasc Surg 1995;109:486493.
3. Lanuti M, Mathisen DJ. Management of complications of
tracheal surgery. Chest Surg Clin North Am 2003;13:385
397.
4. Grillo HC, Mathisen DJ. Primary tracheal tumors: treat-
ment and results. Ann Thorac Surg 1990;49:6977.
5. Wright CD, Grillo HC, Wain JC, et al. Anastomotic
complications after tracheal resection: prognostic factors
and management. J Thorac Cardiovasc Surg 2004;128:
731739.
6. Gaissert H, Grillo HC, Mathisen DJ, Wain JC. Temporary
and permanent restoration of airway continuity with the
tracheal T-tube. J Thorac Cardiovasc Surg 1994;107:600
606.
7. Donahue DM, Grillo HC, Wain JC, et al. Reoperative
tracheal resection and reconstruction for unsuccessful repair
of postintubation stenosis. J Thorac Cardiovasc Surg
1997;114:934938.
8. Silver JR. Paraplegia as a result of tracheal resection in a
17-year-old male. Spinal Cord 2007;45:576578.
9. Ho AM, Dion PW, Karmakar MK, et al. Use of heliox in
critical upper airway obstruction: physical and physiologic
considerations in choosing the optimal helium:oxygen mix.
Resuscitation 2002;52:297300.
Section XII
TRAUMA SURGERY
Edward E. Cornwell III, MD
The only real mistake is the one from which we learn nothing.John Powell
72
Evaluating Trauma Literature
David C. Chang, MD
INTRODUCTION
In some surgical specialties, new procedures and guide-
lines are frequently developed and adopted based on
uncontrolled case series, despite the fact that selection bias
often appears in these series (to select the best possible
surgical candidate patients to demonstrate the feasibility
of the new procedure). This bias makes the results difcult
to generalize to the average patient.
In contrast, conclusions based on carefully analyzed evi-
dence in the literature have played an ever-increasing role
in the development of clinical guidelines in trauma care.
The most prominent early example of evidence-based
guidelines in trauma grew out of important work per-
formed by the Brain Trauma Foundation, in collaboration
with the American Association of Neurologic Surgeons.1
Guidelines were developed around 13 specic clinical
issues in patients with severe traumatic brain injuries.
In highlighting the importance of evidence-based surgi-
cal practice in trauma, this chapter emphasizes specic
pitfalls to be avoided in evaluating the trauma literature.
The example of the evolution of management of traumatic
colon injuries are utilized to illustrate the pitfalls.
PITFALL 1: GENERATING A CLASS I
RECOMMENDATION BASED ON
CLASS III DATA
In 1943, the Surgeon General of the United States issued
guidelines that all colon injuries sustained by soldiers in
the North African theater during World War II be managed
by colostomy either at or proximal to the site of injury,
rather than by primary repair or resection and anasto-
mosis.2 Retrospective analysis of this recommendation
included the observations that colon injuries during the
Civil War carried an associated 90% mortality, whereas
those experienced during World Wars I and II carried a
60% and a 30% mortality, respectively. The reduced mor-
tality of injuries experienced during World War II was
attributed to the policy of mandatory colostomies, ignor-
ing the contribution of advances in uid resuscitation,
plasma preservation, blood-banking techniques, the avail-
ability of antimicrobial agents, and superior military triage
and evacuation.
Consequence
For the two decades after World War II, the military
mandate led to the assumption in civilian practice that
colostomy should be the standard of care for traumatic
colon injuries. This led to thousands of patients receiv-
ing colostomies and the need for subsequent opera-
tions with their associated morbidity. Tradition and
intuition would play a large role in the choice of man-
agement until Stone and Fabian published a report in
19793 comparing the outcomes of colostomies versus
primary repair in patients with less severe injuries.
Repair/Prevention
The prevention of future misassumption is hopefully
feasible with the development of the principles of evi-
dence-based medicine. These principles dictate that
 754 SECTION XII: TRAUMA SURGERY
class II (prospective nonrandomized) and class III (ret-
rospective) data should generate questions rather than
answers. Once the feasibility and estimated complica-
tion rates of two possible treatment arms (colostomy/
diversion versus primary repairs/anastomosis) are
established, the development of clinical guidelines
should ideally be derived from well-designed prospec-
tive, randomized trials. In retrospect, attributing the
decreased mortality from colon injuries in World War
II to the policy of mandatory colostomy was probably
unfairly indicting primary repair and unduly promoting
colostomies.
PITFALL 2: INAPPROPRIATE
COMPARISON OF COMPLICATION
RATES BETWEEN RETROSPECTIVE
AND PROSPECTIVE SERIES
When a clinical researcher and a study nurse formally
dene complications (such as intra-abdominal abscess
after colon repairs) and prospectively compile them, the
magnitude of the complication rates will almost always
be higher than the complication rates generated by chart
reviews and retrospective recall. An example of a remark-
ably low complication rate generated by retrospective
methodology is seen in a 1984 study of traumatic colon
injuries at an urban trauma center.4 In this series of 56
patients over a 6-year period, none developed an intra-
abdominal abscess. These incredible results raise the ques-
tion as to whether more severely injured patients who
developed complications somehow eluded the investiga-
tors chart reviews. Subsequent retrospective series
published over the ensuing decade would echo a near 0%
septic complication rate among patients undergoing
primary repair of penetrating colon injuries.5,6 Interest-
ingly, these excellent outcomes are unattainable when the
same patients are evaluated prospectively.7,8
Consequence
Patients, malpractice attorneys, hospitals, and perfor-
mance-improvement committees may well develop the
unreasonable expectation that the management of
traumatic colon injuries carries a 0% septic complication
rate.
Repair/Prevention
Unlike other elds of medicine, the development of
many surgical treatment modalities remains unregu-
lated; therefore, each new advance in treatment requires
some form of self-regulation. Only by insisting upon
proper interpretation of clinical data and the avoidance
of unsupported conclusions can we guard against the
unrealistic expectation described previously.
PITFALL 3: GENERATING A CLASS I
RECOMMENDATION FROM
CLASS II DATA
When surgeons began to appreciate the difference between
high-velocity military injuries and low-velocity injuries
seen in the civilian setting, the wartime practice of routine
colostomy would gradually come under challenge. A
report in 1951 identied a 9% mortality rate when primary
repair of selected colon injuries was used.9
American surgeons trained from the 1950s through the
1980s developed the ability to identify patients who have
extremely severe injuries and pronounced physiologic
derangement. These sicker patients with predictably higher
complication rates have generally been managed with
colostomies. Not surprisingly, virtually every retrospective
or prospective, nonrandomized study analyzing intra-
abdominal septic complications found that patients who
received primary repair had complication rates equal to or
less than those who received colostomy. This culminated
in a paper in 1997 entitled, Primary repair of 58 con-
secutive penetrating injuries of the colon: should colos-
tomy be abandoned?10
Consequence
Surgeons initially credited colostomy and impugned
primary repair in the 1950s based primarily on class
III data (i.e., retrospective review of data) from World
Wars I and II. Subsequently, surgeons impugned colos-
tomy in the 1980s based on primarily class II data
(prospective but nonrandomized trials), ignoring the
trend that colostomy was becoming reserved for a pro-
gressively severely injured subset of patients.
Repair/Prevention
Clearly septic complications can be predicted to occur
in patients with penetrating colon injuries. The ques-
tion remained whether colostomy decreases that risk,
which can only be answered by prospective, random-
ized analyses in which patients are equally likely to
receive one treatment mode or the other, without
regard to the severity of their injuries. There are four
such trials in the literature.1114 In all four trials, primary
repair patients had outcomes that were as good as those
of colostomy patients.
FUTURE DIRECTIONS
A question arises of whether there are enough severely
injured patients in the prospective randomized trials who
require resection and anastomosis under physiologically
compromised situations to routinely recommend primary
repair in every circumstance. There has been a total of only
37 patients described in the prospective, randomized
studies discussed earlier who underwent resection and
anastomosis; and in three of those four trials, the severity
 72 EVALUATING TRAUMA LITERATURE
of injuries were represented by the groups average Pen-
etrating Abdominal Trauma Index (PATI). Therefore, it
was unclear how many of the 37 patients were at actual
high risk for septic complications. Although none of
the 37 patients had identied suture line disruption, there
appears to be an inadequate number of patients with
destructive colon injuries and other major risk factors to
recommend that colostomies to be abandoned altogether.
Guidelines developed by the Eastern Association for the
Surgery of Trauma (EAST) reect these concerns, reserv-
ing colostomy as a level II recommendation for patients
with destructive colon injuries that require resection in a
setting of shock, underlying disease, or severe associated
injury.15
REFERENCES
1. Brain Trauma Foundation. The integration of brain-
specic treatment to the initial resuscitation of the severe
head injury patient. J Neurotrauma 1996;13:653659.
2. Circular Letter No. 178. Washington, DC: Ofce of the
Surgeon General of the United States. October 23, 1943.
3. Stone HH, Fabian TC. Management of perforating colon
trauma: randomization between primary closure and
exteriorization. Ann Surg 1979;190:430435.
4. Adkins RB Jr, Zirkle PK, Waterhouse G. Penetrating
colon trauma. J Trauma 1984;24:491499.
5. Nallathambi MN, Ivatury RR, Shah PM, et al. Aggressive
denitive management of penetrating colon injuries: 136
cases with 3.7 per cent mortality. J Trauma 1984;24:500
505.
755
6. Levison MA, Thomas DD, Wiencek RG, Wilson RF.
Management of the injured colon: evolving practice at an
urban trauma center. J Trauma 1990;30:247251;
discussion 251253.
7. George SM Jr, Fabian TC, Voeller GR, et al. Primary
repair of colon wounds. A prospective trial in nonselected
patients. Ann Surg 1989;209:728733; discussion 733
734.
8. Demetriades D, Charalambides D, Pantanowitz D.
Gunshot wounds of the colon: role of primary repair. Ann
R Coll Surg Engl 1992;74:381384.
9. Woodhall JP, Ochsner A. The management of perforating
injuries of the colon and rectum in civilian practice.
Surgery 1951;29:305320.
10. Jacobson LE, Gomez GA, Broadie TA. Primary repair of
58 consecutive penetrating injuries of the colon: should
colostomy be abandoned? Am Surg 1997;63:170
177.
11. Chappuis CW, Frey DJ, Dietzen CD, et al. Management
of penetrating colon injuries: a prospective randomized
trial. Ann Surg 1991;213:492498.
12. Falcone RE, Wanamaker SR, Santanello SA, Carey LC.
Colorectal trauma: primary repair or anastomosis with
intracolonic bypass vs ostomy. Dis Colon Rectum 1992;
35:957963.
13. Sasaki LS, Allaben RD, Golwala R, Mittal VK. Primary
repair of colon injuries: a prospective randomized study.
J Trauma 1995;39:895901.
14. Gonzalez RP, Merlotti GJ, Holevar MR. Colostomy in
penetrating colon injuries: is it necessary? J Trauma 1996;
41:271275.
15. Eastern Association for the Surgery of Trauma. Trauma
practice guidelines. 1998. Accessed at www.east.org
73
Evaluation and Acute Resuscitation
of the Trauma Patient
Elliott R. Haut, MD
INTRODUCTION
Although not all trauma patients need surgical interven-
tion, they do require immediate evaluation and resuscita-
tion. Therefore, trauma continues to be a surgical disease.
Early intervention in critically injured patients can signi-
cantly inuence mortality, morbidity, and disability after
major trauma. Patients have improved outcomes when
treated at these specialized centers13 and when additional
resources and commitment are dedicated to trauma
care.46
The Advanced Trauma Life Support (ATLS) course
sponsored by the American College of Surgeons Commit-
tee on Trauma is the gold standard for teaching trauma
management and heavily emphasizes the importance of
the initial trauma resuscitation.7 This chapter utilizes the
ATLS framework to highlight the essentials and potential
pitfalls in the evaluation and resuscitation of the injured
patient.
PRIMARY SURVEY
Upon arrival at the trauma center, rapid primary survey
should include evaluation of the Airway (with cervical
spine protection considered), Breathing and ventilation,
Circulation with hemorrhage control, Disability (neuro-
logic status) and Exposure/Environmental control.
These ABCDEs are the basic initial management empha-
sized by ATLS. Major pitfalls at this point can rapidly
cause death.
It is ideal to strictly adhere to systematic performance
of the primary survey and focus on the ABCDEs to ensure
that the most life-threatening injuries are dealt with rst.
Do not be distracted by major external injuries. Although
these obvious injuries are often quite impressive and
gruesome, they are not immediately life threatening. If
a major nding is identied on the primary survey, it
should be treated immediately before moving on to the
next step.
Airway
Airway management is always the rst step in trauma
evaluation. When in doubt, the safest route is often to
intubate the patient and completely control the airway.
Loss of Airway
Consequence
Loss of airway during trauma resuscitation can rapidly
lead to respiratory and then cardiopulmonary arrest and
death.
Grade 5 complication
Repair
If an airway problem is found, it needs to be denitively
remedied before moving on to breathing and circula-
tion. If at any time during the evaluation the need for
airway control is recognized, start back at airway evalu-
ation and reconsider performing standard endotracheal
intubation.
Prevention
All potential alternatives must be anticipated. Do not
assume that the rst attempt at endotracheal intubation
will be immediately successful. If endotracheal intuba-
tion cannot be done expeditiously, advanced airway
manipulation (e.g., beroptic intubation, laryngeal
mask airway) may be the next attempted maneuver.
The ultimate backup is surgical airway by cricothyrot-
omy, which should be in the armamentarium of every
surgeon treating trauma patients (Fig. 731). Occa-
sional providers still attempt to achieve emergency
surgical airway by means of a tracheostomy. This dan-
gerous practice ignores the anatomic fact that the cri-
cothyroid membrane is the most supercial access point
to the airway and the trachea immediately dives deep
into the mediastinum.
Allowing an Episode of Hypoxia
Consequence
Even short periods of hypoxia are known to worsen
outcomes after traumatic brain injury (TBI).
Grade 4/5 complication
 758 SECTION XII: TRAUMA SURGERY

Hyoid bone
Thyrohyoid m.
Sternohyoid m.
Omohyoid m.
Anterior jugular v. Thyroid cartilage

Cricoid cartilage Cricothyroid membrane

Sternocleidomastoid
muscle

Thyroid gland
isthmus Trachea

MC
A

Skin incision over

cricothyroid membrane

B
Figure 731 Cricothyrotomy. A, The cricothyroid membrane is located between the thyroid cartilage above and the cricoid ring below.
B, The operators nondominant hand holds the thyroid cartilage while the other hand performs the procedure. A vertical skin incision
avoids the anterior jugular veins to minimize bleeding.
 73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT 759

Cricothyroid
membrane

Cricothyroid
membrane

D Cricoid cartilage Thyroid gland

Figure 731, contd C, The cricothyroid membrane is incised transversely. D, The opening is widened with a small hemostat.
 760 SECTION XII: TRAUMA SURGERY

Tracheostomy tube

Tracheostomy tube

Figure 731, contd E, The tracheostomy tube is placed into the airway and the cuff is inated.

Conversion of a Metastable Airway to

Repair
an Unstable Airway
If hypoxia is noted, urgent attention should be paid
to airway management. High-ow oxygen should Consequence
be given. If endotracheal intubation is not successful, Conversion of a metastable airway to an unstable airway
surgical airway (cricothyrotomy) should be rapidly can rapidly change a difcult situation into an impos-
performed. sible one. Death from airway loss is never a pretty
sight.
Prevention Grade 5 complication
Delays in obtaining a denitive airway can lead to
hypoxia, which has signicant negative impact on out- Repair
comes in head-injured patients. This is yet another Often, this error leads to emergent cricothyrotomy
reason why airway management is the rst critical step instead of a smoother, controlled airway management
in trauma evaluation. scheme.
 73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT
Prevention
Before dosing a patient with paralytics for rapid-
sequence intubation, consider the potential conse-
quences in a patient with a metastable airway. Paralytics
may convert a patient who is protecting her or his own
airway and able to oxygenate and ventilate to a patient
who is no longer breathing and is unable to be intu-
bated. Consider letting the patient sit up to help clear
blood and secretions, rather than making her or him
lay at and possibly inducing aspiration.
Causing Worse Neurologic Injury with
Spine Manipulation
Consequence
Exacerbating neurologic decits by not immobilizing
the cervical spine can have long-lasting devastating
consequences. Patients with spinal column injuries may
have no neurologic decit or only an incomplete spinal
cord injury. It is incredibly tragic when patients such
as this have worsening of their injury from inappropri-
ate cervical spine immobilization.
Grade 4/5 complication
Prevention
Cervical spine stabilization is emphasized during airway
management by ensuring that the head stays in neutral
position. Hyperextending the neck in a patient with an
unstable cercival spine injury may change a patients
functional outcome signicantly by exacerbating neu-
rologic injury. A patient may be rendered permanently
quadriplegic with even small manipulations of the
neck.
Breathing
The next step of evaluation during the trauma resuscita-
tion is breathing and ventilation. Often, it is quite difcult
to differentiate a breathing problem from an airway issue.
In this situation, if the airway is controlled and the problem
continues, there is most likely a lung or breathing problem.
Physical examination is the key rst maneuver to making
the appropriate diagnosis.
Missed Tension Pneumothorax on
Physical Examination
Consequence
Missing tension pneumothorax on physical examina-
tion or waiting for a conrmatory chest x-ray can lead
to an unnecessary prolonged period of hypotension,
shock, hypoperfusion, anoxic brain injury, and/or
death.
Grade 5 complication
Repair
Immediate chest decompression (by needle) followed
by tube thoracostomy.
761
Prevention
Decreased breath sounds on one side should lead to an
immediate chest tube before radiographic evaluation
in patients with signicant respiratory distress or shock.
In this case, treatment of a tension pneumothorax can
be life saving. Tension pneumothorax should be a clin-
ical diagnosis made by physical examination, not radio-
graphically. Tracheal deviation (away from the tension
pneumothorax) helps conrm the diagnosis in patients
with decreased breath sounds and hypotension.
Placing an Unnecessary Chest Tube
Consequence
Tube thoracostomy is not a benign procedure. It is
associated with injury to structures within the chest and
abdomen and has the potential to cause infection.
Appropriate tube thoracostomy placement can be nec-
essary; however, if a patient does not need a chest tube,
we should not place one.
Grade 2 complication
Prevention
In the hemodynamically stable patient who is physio-
logically normal from a respiratory standpoint (e.g., no
hypoxia, shortness of breath, use of accessory muscles),
consider getting an early chest x-ray to clearly dene
whether a hemo- and/or pneumothorax is present
before intervention. Providers must always be cogni-
zant of the benet of listening very closely with an
unbiased stethoscope. Often, when there is a wound
over one hemithorax, we expect (and subsequently
believe we nd) decreased breath sounds when there
may be no anatomic pathology. An early chest x-ray
can save the patient a potentially unnecessary chest tube
placed for unequal breath sounds in the physiologi-
cally normal trauma patient. However, this recommen-
dation should not be taken as a suggestion to wait for
a chest x-ray in an unstable patient with signs of respi-
ratory distress or tension pneumothorax.
Conversion of Simple Pneumothorax to Tension
Pneumothorax with Positive-Pressure Ventilation
Consequence
Trauma patients may have a small pneumothorax,
which may be too small to see on chest x-ray or com-
puted tomography (CT) scan. These may be of no
consequence and heal on their own without interven-
tion. However, if there is a hole in the visceral pleura
over the lung, this simple pneumothorax can be con-
verted to a tension pneumothorax with positive-
pressure ventilation.
Grade 5 complication
Repair
Immediate chest decompression (by needle) followed
by tube thoracostomy.
 762 SECTION XII: TRAUMA SURGERY
Prevention
Ventilation may rapidly deteriorate with endotracheal
intubation and positive-pressure ventilation owing to
a worsening pneumothorax. In patients with known
pneumothorax, consider placing a chest tube as soon
as the patient is intubated, rather than waiting until a
conrmatory chest x-ray is performed.
Main Stem Intubation Leading to Unnecessary
Chest Tube
Consequence
Straightforward successful intubation is the expected
outcome after plans for controlling the airway. Main
stem intubation is a common minor complication of
endotracheal intubation. In and of itself, it does not
cause major problems. However, if unrecognized, it
may lead the team to perform further procedures (e.g.,
tube thoracostomy for presumed hemo- or pneumo-
thorax owing to decreased or absent breath sounds)
before the simple diagnosis is made.
Grade 2 complication
Repair
Pull the endotracheal tube back to the appropriate
position and reconrm by chest x-ray or beroptic
bronchoscopy.
Prevention
Main stem intubation (more commonly into the right
main stem bronchus) can give the appearance of chest
pathology owing to absent or decreased breath sounds.
Always consider this possibility rather than assuming
another lung pathology (such as hemo- or pneumotho-
rax). Conrming endotracheal tube placement by early
chest x-ray or pulling the endotracheal tube back may
avoid an unnecessary tube thoracostomy.
Air Embolism
Consequence
Intubation and positive-pressure ventilation may cause
air embolism. Hypovolemic patients whose penetrating
injuries produce direct communications between the
small airways and the pulmonary venous tributaries are
at particularly high risk. When positive pressure is
applied to the bronchial tree, air may go through these
abnormal connections and eventually enter the left side
of the heart. Air can then ow to the brain causing
stroke or the coronary arteries causing myocardial
infarction.
Grade 4/5 complication
Repair
Initial treatment includes increasing the fraction of
inspired oxygen (FIO ). Hyperbaric oxygen therapy may
2
have a role, but there are no large studies to prove its
benet.
Prevention
Air embolism is difcult to prevent. Key maneuvers
include minimizing the time of positive-pressure venti-
lation before attempting surgical control of a penetrat-
ing lung injury. Prompt hydration and uid resuscitation
will also help ensure a full venous system, which may
help prevent air embolism as well.
Circulation
Uncontrolled External Hemorrhage
Consequence
Ongoing external hemorrhage can rapidly lead to
shock, exsanguination, and death.
Grade 5 complication
Repair
Control of external hemorrhage during the early phase
(circulation) of resuscitation is imperative.
Prevention
External bleeding is best controlled by direct digital
pressure. Frequently, a patient with a small head lac-
eration presents to the trauma center with a large,
loosely wrapped, bulky gauze dressing saturated with
blood. When the trauma team removes this dressing
and sees a 2-cm laceration, digital pressure from one
nger can completely stop this external hemorrhage
and save multiple units of blood transfusions for this
patient.
Exacerbating a Vascular Injury by
Blind Clamping
Consequence
Blindly placing a clamp into a bleeding wound has
considerable potential to enlarge a small arterial or
venous injury. This may change the necessary surgical
procedure signicantly. What may have taken one or
two simple sutures may now require a complex vascular
repair.
Grade 3/4 complication
Repair
Surgical repair of major vascular injury as indicated will
be the only way to correct this injury. These more
complex injuries may require an interposition vein or
prosthetic conduit placement to restore ow to the
injured extremity.
Prevention
In the extremities, external bleeding is often best con-
trolled with digital pressure directly on the bleeding
wound. Blind clamping should be avoided to prevent
further major vascular injury. Imprecise clamp place-
ment can convert a small partial-thickness arterial injury
to a complete transaction requiring a larger, more
complex arterial reconstruction. Although there is con-
 73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT
troversy about their use, tourniquets may be considered
if direct pressure does not stop the ongoing hemor-
rhage.8 A blood pressure cuff placed directly over the
wound and inated to above the arterial blood pressure
should temporize the situation and control external
hemorrhage while the rest of the ABCDEs are addressed.
The primary and secondary surveys can be nished
expeditiously while a denitive plan (surgical explora-
tion) for hemorrhage control is undertaken.
Assuming that a Normal Heart Rate or Blood
Pressure Ensures that a Patient Is Not in Shock
Consequence
Making a false assumption such as this will ultimately
delay the diagnosis of shock. This may allow a patient
enough time to continue to exsanguinate. Hemorrhage
is a major cause of death after trauma. In a recent
review of 2594 deaths at a large regional trauma center,
delayed intervention for hemorrhage accounted for the
largest percentage of preventable death.9
Grade 5 complication
Repair
As soon as the diagnosis of shock is made, work-up
directed at the differential diagnosis of bleeding sites is
imperative. Ongoing active uid resuscitation should
be performed simultaneously during this evaluation.
Prevention
Early consideration of control of internal hemorrhage
is important, although this often falls into the second-
ary survey in hemodynamically stable patients. Pitfalls
during this portion of resuscitation can occur in specic
patient populations. Young, well-trained athletes and
patients who are well -blocked will continue with a
normal heart rate (or bradycardia), even after signi-
cant blood loss has occurred. Patients in class II hemor-
rhagic shock (blood loss of 15%30% of blood volume
or 7501500 ml) will compensate with tachycardia and
vasoconstriction but may still have normal vital signs.
The only physical examination nding may be a narrow
pulse pressure. Take the example of a patient whose
baseline blood pressure is 120/80 mm Hg and heart
rate is 60. His or her vital signs after trauma (blood
pressure 110/90 mm Hg and pulse 90) may be in the
overall normal range but represent a 50% decrease in
pulse pressure and a 50% increase in heart rate.
Elderly patients also may not exhibit typical signs and
symptoms of hemorrhage and shock (e.g., tachycardia,
hypotension) after major trauma. These patients may not
have the physiologic reserve that their younger counter-
parts do. Extra vigilance must be used in elderly trauma
patients to ensure timely diagnosis and treatment because
elderly patient may not be able to recover if the therapy
is delayed. Trauma team activation and early intensive
monitoring may improve outcomes in trauma patients
older than 70 years.10,11
763
Assuming Hemodynamic Stability Excludes
Signicant Hemorrhage after Penetrating
Abdominal Trauma
Consequence
Delay in laparotomy once the diagnosis of peritonitis
is made can allow a longer period of bleeding and
abdominal contamination. This may lead to the need
for more extensive surgery, higher rates of abdominal
sepsis, and death.
Grade 35 complication
Repair
Early laparotomy should be undertaken as soon as signs
of bleeding (i.e., dropping hemoglobin or hematocrit,
hypotension) or peritonitis occur.
Prevention
In the modern era of selective management of pene-
trating abdominal trauma, not all patients with stab or
gunshot wounds require mandatory laparotomy, as was
the practice pattern for many years. Patients with a
completely benign abdominal examination and normal
vital signs may be safely treated expectantly, but the
trauma team should be ready and willing to operate
immediately at the rst sign of clinical deterioration.
Even patients who are stable at initial presentation may
have signicant injury. A recent review of 139 hemody-
namically stable patients with penetrating abdominal
trauma in whom peritonitis was the sole indication for
laparotomy highlighted this point. In this large series from
a busy trauma center in Los Angeles, major vascular injury
(11%), intraoperative hypotension (25%), and blood trans-
fusion (39%) were common. Nearly half of the patients
required intensive care, 25% had at least one complica-
tion and 3 died (including 2 from exsanguination).12
Peritonitis should triage patients for emergent operation
regardless of vital signs.
Disability
Not Intubating a Patient with a Glasgow Coma
Scale Score of 8 or Lower
Consequence
Failure to intubate a patient with a Glascow Coma
Score (GCS) of 8 or lower may lead to hypoxia and
cause secondary brain injury and worsen functional
outcomes after TBI.13
Grade 4 complication
Delay in intubation can also lead to aspiration in the
patient who is unable to control her or his airway.
Grade 3 complication
Repair
Intubate as soon as possible when a GCS of 8 or lower
is noted.
 764 SECTION XII: TRAUMA SURGERY

Table 731 Glasgow Coma Scale Score Prevention

Motor Verbal Eye Opening It is often difcult to determine which patients have a
TBI and which patients are confused or agitated for
6 Obeys commands 5 Oriented 4 Spontaneous different reasons. The signs and symptoms of acute
5 Localizes pain 4 Confused 3 To voice mental status change have a long list of differential
diagnoses. Patients can have altered mental status
4 Withdraws to pain 3 Inappropriate words 2 To pain
owing to intoxication with alcohol and/or other drugs.
3 Flexion to pain 2 Incomprehensible 1 None Other causes such as hypoglycemia, hypoxia, hypercar-
(decorticate sounds bia, and hypotension resulting in shock must be con-
posturing) sidered and not missed or attributed to head injury,
2 Extension to pain 1 None drugs, or alcohol. In the belligerent, aggressive patient,
(decerebrate the entire list must be considered and each item should
posturing) be ruled out before assuming that intoxication is the
1 None only signicant cause of behavioral problems.
Missing a Subtle Spinal Cord Injury
Consequence
Prevention Early diagnosis of spinal cord injury with neurologic
Use the GCS, which is the standard tool and a quick decit may give the patient the best possible outcome
reliable score, to determine eventual outcome after a by preserving any remaining neurologic function
head injury (Table 731). All trauma patients should and potentially reversing the cause and allowing
have the GCS completed even if there is no obvious/ improvement.
overt head injury. If the GCS is 8 or lower, the patient Grade 4 complication
should be immediately intubated owing to the risk of
not being able to control or protect his or her own Repair
airway. As soon as the spinal cord syndrome is identied,
appropriate neurosurgical consultation and interven-
Hypotension
tion have the best chance to improve outcome.
Consequence
Even a single episode of hypotension can worsen a Prevention
patients functional status after TBI.13 The disability evaluation must include a gross motor
Grade 4 complication examination of both the upper and the lower extremities
to avoid missing a clinically signicant spinal cord injury.
Repair The motor component of the GCS is scored, paying ca
Aggressively treat hypotension in the setting of reful attention to the ability to follow commands. A
TBI. Aggressive uid resuscitation, blood transfusion, patient with a spinal cord injury and complete extremity
and vasopressors are often part of the treatment paralysis may still potentially have a GCS of 15. As long
algorithm. as the patient can follow any motor command, for
example, with her or his eyes, she or he can still have a
Prevention normal GCS. Never perform the motor examination of
Patients with TBI have already suffered their primary the lower extremities only and assume that if the lower
insult. The most important thing we can do for them extremities are intact, the patient has no chance of
is to prevent secondary brain injury. Hypotension is a having a spinal cord injury. This premise is incorrect.
well-described cause of secondary brain injury and Patients with cervical spine stenosis may have a central
should be avoided.13 cord syndrome and have physical ndings only in the
upper extremities with normal lower extremities. Fre-
Attributing Mental Status Change to
quent, neurologic reevaluation is critical to ensure early
Drug Intoxication
identication of any decrement in function.
Consequence
Delay in diagnosis of TBI can have dire consequences Exposure/Environmental
ranging from permanent neurologic disability to
Hypothermia
death.
Grade 4/5 complication Consequence
Hypothermia can lead to many downstream effects
Repair such as confusion, mental status changes, electrolyte
Immediate appropriate work-up to rule out anatomic abnormalities, cardiac arrhythmias, and death.
or physiologic brain injury is indicated. Grade 4/5 complication
 73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT
Repair
Immediate active warming of the patient should begin
when the diagnosis of hypothermia is made.
Prevention
The exact steps in exposure and environmental evalu-
ation depend on the patients specic situation. In the
hospital setting (e.g., in the trauma bay), the patient
should be fully disrobed and all wounds should be
evaluated along with the rest of the patients physical
examination. However, every effort must be made to
avoid hypothermia, which has deleterious effects on
most organ systems. Warming blankets, heat lamps,
and warm intravenous (IV) uids are utilized as soon
as practically possible. Patients can get severely hypo-
thermic in a room that is not that cold. Even on a
warm, sunny, 80 day, a trauma patient may lose the
ability to autoregulate temperature and can become
severely hypothermic.
EARLY INTERVENTIONS
Venous Access
Placement of Insufcient IV Access
Consequence
Using the wrong size of IV catheter for uid resuscita-
tion can lead to signicant underresuscitation of the
severely injured trauma patient. This can lead to
ongoing shock, multiple organ failure, and death if not
rapidly remedied.
Grade 4/5 complication
Repair
Place at least two appropriate large-bore IV lines. A
short, large-bore catheter is the preferred line of
choice.
Prevention
One of the most important early adjuncts to the primary
resuscitation is adequate venous access for uid resus-
citation and medication administration. Optimal venous
access is often obtained in the prehospital setting with
a peripheral IV in the forearm or antecubital fossa. For
patients in whom peripheral IV access cannot be
obtained, the next step is placement of a central venous
line via the Seldinger technique. A short, large-bore
catheter will have optimal ow rates and is best to
enable rapid uid administration. Placement of a longer,
narrow-gauge (e.g., triple-lumen) catheter in this situ-
ation would be inappropriate because the smaller diam-
eter and longer length signicantly impede ow.
Emergent central venous access placement can be per-
formed in the internal jugular, subclavian, or femoral vein.
The anatomic location of choice will depend on the
patients injury pattern. Trauma patients often have a cer-
vical collar blocking access to the jugular vein and ruling
765
out this site. The femoral position gives the easiest access
when multiple other procedures are being performed
simultaneously on the patients airway and chest. However,
femoral access has signicant drawbacks. Femoral cannu-
lation is more difcult to place based on anatomic land-
marks alone, has a higher rate of deep vein thrombosis,
and is relatively contraindicated in patients with pelvic
and/or extremity injuries. The subclavian vein probably
has the most constant anatomic position, making it ideally
suited for placement by anatomic landmarks. However, it
does pose the risk of hemo- and pneumothorax.
Central Venous Access Complications
These are discussed in Section I, Chapter 7, Laparoscopic
Surgery.
Inability to Obtain Venous Access
Consequence
Inability to obtain venous access can cause signicant
morbidity and mortality. Life-saving uids, blood,
and medications are necessary to further an ongoing
resuscitation.
Grade 4/5 complication
Repair
Consider intraosseous needle placement (even in adults)
as an alternative for uid, blood, and drug administra-
tion. Use the endotracheal or intramuscular (IM)
routes as appropriate.
Prevention
Other potential sources of venous access exist for
difcult cases. Intraosseous needle placement (e.g,
proximal tibia) has been a standard alternative IV access
in children under 6 years of age. More recently, the
intraosseous route has been found to be acceptable in
older children and adults as well.14 Venous cutdown is
still an option, but it has been replaced by the more
commonly performed percutaneous route. Some med-
ications can be given down the endotracheal tube (if
the patient is intubated). These medications can be
remembered by the simple mnemonic NAVEL (nalox-
one, atropine, vasopressin, epinephrine, lidocaine). Use
the IM route for medications needed to enable intuba-
tion of a combative trauma patient in whom IV access
is not obtainable. Ketamine and succinylcholine can be
given intramuscularly for sedation and paralysis to allow
intubation.
Resuscitation through a Femoral Venous
Cannula in Cases of Major Abdominal
Venous Injury
Consequence
If uids, blood, or blood products are given through
a femoral venous central line but bleed out into the
abdominal cavity from a major venous injury (e.g.,
vena cava, iliac, hepatic), the patient will not get any
 766 SECTION XII: TRAUMA SURGERY
benet of the attempted resuscitation. This will lead to
ongoing shock, hemorrhage, and death.
Grade 5 complication
Repair
Venous access should be obtained in the antecubital
fossa or a central vein above the diaphragm (internal
jugular or subclavian).
Prevention
In certain situations, venous access above the dia-
phragm is more important than venous access below
the diaphragm. The pitfall of placing the line in the
femoral position begins with assuming that resuscita-
tive uids (or blood) given through a femoral vein
reach the heart and central circulation. This assump-
tion may be incorrect in the case of iliac vein, inferior
vena cava, or hepatic vein injuries. Large amounts of
blood and uid resuscitation given through the groin
may not stay intravascular, but rather end up pouring
out of the venous hole and not helping the patients
hemodynamics as expected.
Gastric and Urinary Decompression
Adjuncts such as gastric and urinary decompression
can be performed simultaneously with the rest of the
evaluation and play an important role in the early resusci-
tation. ATLS suggests that these should be adjuncts to
the primary survey,7 although in many instances, these
commonly wait until after the secondary survey is
performed.
Placing a Nasogastric Tube outside Its Normal
Anatomic Pathway
Consequence
Gastric catheters can be necessary for gastric decom-
pression, but they have associated risks. The most dev-
astating complication is seen when the nasal route is
chosen in a patient with a basilar skull or cribriform
plate fracture. The nasogastric tube easily passes through
the nares and directly into the brain.
Grade 4/5 complication
Prevention
In patients with known (or suspected) skull base frac-
tures, the nasal route is contraindicated for both gastric
decompression and endotracheal intubation. In intu-
bated patients, the orogastric route is preferred.
Exacerbation of a Minor Urethral Tear into
a Complete Transaction
Consequence
Foley catheter insertion is important to measure urine
output (as a marker of adequate resuscitation) and look
for blood (gross and microscopic) in the urine.
However, there is a risk of urethral injury when the
catheter is placed. In patients with incomplete urethral
injuries, blind placement is contraindicated. This blind
attempt at placement may convert a small, partial ure-
thral tear into a complete transaction.
Grade 2/3 complication
Repair
Urologic consultation will most likely be helpful in
these situations. Repair will often necessitate suprapu-
bic tube placement, cystoscopy for Foley catheter
placement, and possibly, direct surgical repair of the
torn urethra.
Prevention
There is a potential hazard in placing these urinary
catheters, especially in patients with complex pelvic
fractures and urethral injury. These injuries occur in
men with some regularity. They are rare in women;
however, the notion that they never occur is incor-
rect.15 Thorough physical examination should be per-
formed to rule out the urethral injury before placement
of a Foley catheter. Identication of blood at the penile
meatus (or introitus), perineal ecchymosis, scrotal
hematoma, a high-riding or nonpalpable prostate, gross
hematuria, or complex pelvic fracture should serve
notice of potential urethral injury. In this case, a retro-
grade urethrogram is warranted to rule out urethral
injury before placement of a Foley catheter blindly.
Skipping this crucial step can convert a minor urethral
tear into a complete transaction.
Assessment of the Need for Transfer
Delaying Transfer
Consequence
Delayed recognition of the patient who needs to be
transferred potentially inuences eventual morbidity
and mortality.
Grade 15 complication
Repair
Arrange for transfer (if appropriate) as soon as possible
after immediate stabilization of the patient.
Prevention
Transfers of trauma patients are common when an
additional higher level of care is necessary. Early
consideration of the need to transfer should be enter-
tained, but it should not delay resuscitative measures.
Often, basic measures and procedures (e.g., intubation,
tube thoracostomy, venous access) must be performed
just to stabilize the patient enough for a safe transfer.
A small, nontrauma hospital may not have the resources
(e.g., operating room, radiology, intensive care unit,
blood bank) to handle a patient, even though an
individual trauma surgeon working there may be com-
fortable doing so.
 73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT
SECONDARY SURVEY
Missed Injury
Consequence
Grade 15 complication
Repair
Treatment for any injury should be performed (or
planned for) as soon as the injury is identied.
Prevention
The secondary survey immediately follows the primary
survey and associated adjuncts to resuscitation. This
secondary survey consists of a thorough, systematic,
head-to-toe physical examination. This examination
should be done in the same order on every patient,
reducing the potential pitfall of missing any injury,
however small it may be. Abnormal physical examina-
tion ndings may direct one toward further evaluation
and work-up. Certain physical ndings are hallmarks
of traumatic injuries and, when recognized, prompt
further diagnostic evaluation. Seat belt signs are
severely bruised areas where a shoulder belt or lap belt
crosses the body. When found over the neck, blunt
cerebrovascular injury (BCVI) and cervical spine injury
should be considered. A seat belt sign over the torso
prompts concern of sternal fracture, hollow viscus
injury, and lumbar spine fracture (Chance fracture).
The handlebar of a bicycle can cause a classic circular
injury pattern that should prompt consideration of
hollow viscus and solid organ injury.
Incorrect Assessment of Patients with
Gunshot Wounds
Consequence
Incorrect assessment of patients with gunshot wounds
can lead to missed injuries and delays in diagnosis.
Some complications may be insignicant, but others
may have major implications. Delayed diagnoses may
lengthen hospital stay and lead to worse clinical out-
comes, organ failure, amputation, and death, depend-
ing on the injuries. Inappropriate judgment may also
lead to unnecessary operations and/or procedures,
which could be avoided by correct assessment.
Grade 15 complication
Repair
The situation can be remedied by careful reevaluation
and assessment (making sure the number of holes plus
the number of bullets is an even number). As soon as
a potential injury is identied, appropriate work-up and
evaluation should be performed.
Prevention
In patients with gunshot wounds, it is imperative to
count the number of gunshot wounds and identify all
767
bullets retained in the patients body. When added
together, this number must be even. Every bullet either
makes an entrance and an exit wound or leaves a
retained bullet. If the initial count is an odd number,
the trauma surgeon may have made a mistake and must
correct it immediately. Inadequate physical examina-
tion may miss holes within the hairlines, axilla, soft
tissue folds, mouth, rectum, or vagina. Retained bullets
are commonly missed on x-rays when the area between
the chest and the pelvis lms is not adequately inter-
rogated radiographically or the soft tissues are not
included on a chest x-ray of an obese patient. CT scan
can be benecial, even if only the scout lm is used
to look for retained bullets. You may count up to an
odd number erroneously if an old bullet (from a prior
gunshot wound) is counted. Ask patients if they have
been shot before; specically question where they have
retained bullets and subtract these from the count.
TREATMENT OF SPECIFIC INJURIES
Pelvic Injury
Although suggested by ATLS, not every trauma patient
needs a plain pelvic x-ray.7 The pelvic x-ray has limited
sensitivity (68% in adults and 54% in children) for detect-
ing pelvic fractures compared with CT scanning. Patients
who are hemodynamically stable and are going to get an
abdominopelvic CT scan during their immediate resusci-
tation do not need a plain pelvic x-ray. Early pelvic x-ray
may be helpful in hemodynamically unstable patients,
those with signicant physical ndings, and those who will
not undergo immediate abdominopelvic CT scanning
because of other clinical priorities.16
Ongoing Pelvic Hemorrhage
Consequence
Ongoing bleeding within the pelvis can have the same
complications of bleeding as in all other patients (exsan-
guination, death). However, more commonly, it will
lead to unnecessary blood transfusions, ongoing shock
with hypotension and hypoperfusion, and further
searches for possible bleeding sites.
Grade 25 complication
Repair
Placement of a pelvic binder or external xator to close
down pelvic volume should be done as soon as an
unstable pelvis at high bleeding risk is found.
Prevention
Clinical assessment of the pelvis early in resuscitation is
important because pelvic hemorrhage is a common
cause for shock after blunt trauma.17 The pelvis is rst
examined by lateral compression, looking for an unsta-
ble pelvic fracture. If the pelvis can be compressed, the
examination should stop. Although this may seem like
 768 SECTION XII: TRAUMA SURGERY

an ideal teaching case for every resident and student to

examine the grossly unstable pelvis, this should not be
done; only one person should examine the unstable
pelvis. Every manipulation causes more arterial and
venous bleeding from the pelvic fractures, only worsen-
ing the situation. A pelvic binder should be placed to
close down the pelvic volume to control hemorrhage.
External binding for pelvic stabilization is accomplished
by using either a tightly wrapped bed sheet or a com-
mercially available device (e.g., PelvicBinder) (Fig.
732).

Getting a Pelvic CT Scan without IV Contrast

Consequence A
A pelvic CT scan without IV contrast cannot fully
evaluate for contrast blush in the pelvis. This can lead
to missing pelvic bleeding as a source of ongoing
hemorrhage that may lead to shock, necessitate more
blood transfusion, and possibly, lead to death.
Grade 25 complication
Repair
Always order a CT scan of the pelvis with IV contrast
administration. The same contrast bolus can be used to
evaluate the rest of the torso (chest and abdomen) to
screen for blunt aortic and/or solid organ injury, which
is commonly associated with complex pelvic fractures.
Prevention
Abdominopelvic CT scan with IV contrast is critical to
B
dene the pelvic fracture and to evaluate for pelvic
hematoma and arterial contrast blush (extravasa-
tion).18,19 The nding of arterial extravasation warrants
immediate arteriography with therapeutic angioembo-
lization. Angiographic embolization has rapidly become
the standard of care for hemorrhage control after pelvic
injury because operative attempts to control such bleed-
ing are often unsuccessful. Pelvic vessel embolization
has been shown to be safe and effective to control
hemorrhage.20 Its application should be applied liber-
ally. Older age (>60 yr) is associated with a higher risk
of bleeding requiring intervention.21 Some trauma sur-
geons have suggested that certain specic anatomic
injuries are associated with higher rates of bleeding.22,23
C
However, others have shown that the fracture pattern
may not reliably predict which patients will benet Figure 732 A, Pelvic x-ray of a patient with a complex pelvic
from intervention.24 Repeat angiography is warranted fracture and pubic symphysis diastasis. B, Pelvic x-ray of the same
in cases of ongoing hemorrhage and shock, even after patient after placement of the PelvicBinder. C, A patient with the
initially normal angiography.25 PelvicBinder in place. (AC, Courtesy of and reproduced with
permission of PelvicBinder, Inc., Dallas, TX.)

Blunt Cerebrovascular Injury (BCVI)

Delayed Diagnosis of BCVI in a Neurologically
Normal Patient
Consequence
BCVI is a rare but devastating injury seen in trauma
patients. BCVI is most often associated with a high-
speed deceleration mechanism or a direct blow to the
cervical area. The rst sign or symptom of BCVI can
be a massive stroke, after which clinical outcome is
often poor.
Grade 4/5 complication
Prevention
Aggressive screening practices are suggested to prevent
this dreaded complication.2628 Patients with signicant
 73 EVALUATION AND ACUTE RESUSCITATION OF THE TRAUMA PATIENT
Box 731 Proposed Criteria for Screening for
Blunt Cerebral Vascular Injury (BCVI)
History
Injury mechanism consistent with severe neck hyperex-
tension, rotation, or hyperexion
Hanging
Amaurosis fugax
Physical Examination
Arterial hemorrhage from the head or face from the
mouth, nose, ears, or wounds
Massive epistaxis
Expanding cervical hematoma
Bruit in the neck of a young patient (<50 yr)
Complex facial or mandible fractures
Severe closed head injury
Seat belt sign across the neck
Anisocoria
Unexplained mono- or hemiparesis
Neurologic examination unexplained by head computed
tomography (CT) scan
Glasgow Coma Scale score 8 (in the eld or in the
emergency department)
Lateralizing neurologic signs
Cerebrovascular accident (CVA)
Transient ischemic attack (TIA)
Horners syndrome
Radiographic ndings
Complex facial or mandible fractures
Cervical spine fracture
Basilar skull fracture through or near the carotid canal
Fracture through the foramen transversarium
Cerebral infarction on CT scan
risk factors for BCVI should have liberal screening to
avoid the potential pitfall of delayed stroke that can be
prevented by earlier injury identication and treatment
with anticoagulation (e.g., heparin, antiplatelet agents).
Although denitive criteria for screening are not clearly
dened, many signs and symptoms have been sug-
gested to predict a high risk of BCVI26,29 (Box 731).
The gold standard for screening these patients has been
conventional catheter-based angiography. Newer data
have suggested that multi-lanar CT angiography is a
promising screening modality.3034
Hypotensive Blunt Trauma Patient
The hypotensive blunt trauma patient presents many
potential areas to make mistakes with dire consequences.
These patients need immediate, rapid evaluation with con-
current resuscitation in an attempt to stay alive.
Not Rapidly Identifying the Site of Bleeding
Consequence
Delayed diagnosis of the source and site of bleeding in
a hypotensive blunt trauma patient can rapidly lead to
hypotension, shock, and death from exsanguination.
Grade 4/5 complication
769
Repair
Rapidly search for or rule out bleeding from all poten-
tial sites including the chest, abdomen, pelvis, retro-
peritoneum, and extremities and observe for external
blood loss.
Prevention
Hemorrhage is the number-one potential cause of
shock in these patients, and it must be ruled out quickly.
Only a nite number of places exist in which an adult
patient can bleed enough to go into hemorrhagic
shock. These include the chest, abdomen, pelvis, ret-
roperitoneum, extremities, and external blood loss.
Most of these areas are rapidly assessed with physical
examination, two plain x-rays (chest and pelvis) and
focused abdominal sonography for trauma (FAST).
Provider-performed FAST is a quick, reliable, noninva-
sive ultrasound designed to identify hemopericardium
and/or hemoperitoneum. It has almost universally
replaced diagnostic peritoneal lavage for identifying
intra-abdominal hemorrhage in hypotensive blunt
trauma patients. If enough blood is lost into the
abdomen to cause hemorrhagic shock, this should be
clearly apparent on FAST (Fig. 733). In the rst major
series, FAST was 100% sensitive and specic for iden-
tifying or ruling out intra-abdominal bleeding as the
source of hypotension in blunt trauma patients.35 Other
series have also shown that abdominal uid is nearly
always identied when present.36,37 If positive, rapid
exploratory laparotomy is indicated to control bleed-
ing. If the FAST is unavailable, diagnostic peritoneal
lavage can still be used to determine whether abdomi-
nal bleeding is the cause of hypotension.
Missed Cause of Shock
Consequence
Although hemorrhage is the most common cause of
shock in these patients, it is not the only one. Other
causes do occur including obstructive (tension pneu-
mothorax or cardiac tamponade), neurogenic, cardio-
genic, and anaphylactic shock.
Grade 4/5 complication
Repair
If all potential sites of bleeding have been ruled
out, consider other possible causes of post-traumatic
shock.
Prevention
If the FAST and radiographs are negative, consider the
other rare causes of post-traumatic shock in patients
who are persistently hypotensive. Obstructive shock
(cardiac tamponade and/or tension pneumothorax)
should be reconsidered, and if any doubt remains, steps
should be taken to correct this. Neurogenic shock is
rare, and its diagnosis is commonly delayed. Neuro-
genic shock is ruled out quickly by observing patients
moving all their extremities. Physical examination
 770 SECTION XII: TRAUMA SURGERY
Normal
Kidney
Liver
A 2. Demetriades D, Martin M, Salim A, et al. Relationship
Diaphragm
Hemoperitoneum
Fluid
Liver
Kidney
B impact of changing trauma level designation from II to I.
Diaphragm
Figure 733 Focused abdominal sonography for trauma (FAST)
examination. A, Normal right upper quadrant view. B, Abnormal
right upper quadrant view shows uid between the kidney and the
liver. (A and B, Reproduced with permission of Thomas Scalea,
MD.)
ndings consistent with neurogenic shock include
hypotension, bradycardia, and warm skin (as opposed
to the patient in hemorrhagic shock who is hypotensive
and tachycardic with cool skin). In the obtunded or
intubated patient, an early lateral cervical spine lm is
imperative to identify cervical spine fracture and help
identify neurogenic shock early. A recently reported
case highlighted the major pitfall of delay in diagnosis
of neurogenic shock.38 Neurogenic shock went unrec-
ognized, resulting in an unnecessary (and negative)
laparotomy for presumed bleeding. Although the death
was not preventable, the laparotomy was avoidable.38
Cardiogenic shock from blunt cardiac injury (BCI)
is a rare nding in an alive trauma patient. BCI is
always dened by its physiologic effect and can include
(1) septal rupture, (2) free wall rupture, (3) coronary
artery thrombosis, (4) cardiac failure, (5) minor
electrocardiographic cardiac enzyme abnormality, or
(6) complex arrhythmia with cardiac failure. Formal
echocardiography is necessary to identify wall motion
abnormalities and anatomic defects.3941 Anaphylaxis
and sepsis are exceedingly uncommon causes of shock
after trauma, but if all other causes have been ruled out,
these possibilities must be considered.
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15. Black PC, Miller EA, Porter JR, Wessells H. Urethral and
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16. Guillamondegui OD, Pryor JP, Gracias VH, et al. Pelvic
radiography in blunt trauma resuscitation: a diminishing
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17. DiGiacomo JC, Bonadies JA, Cole FJ, et al. Practice
Management Guidelines for Hemorrhage in Pelvic
Fracture. The Eastern Association for the Surgery of
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18. Pereira SJ, OBrien DP, Luchette FA, et al. Dynamic
helical computed tomography scan accurately detects
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19. Ryan MF, Hamilton PA, Chu P, Hanaghan J. Active
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20. Velmahos GC, Toutouzas KG, Vassiliu P, et al. A
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21. Kimbrell BJ, Velmahos GC, Chan LS, Demetriades D.
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screening for blunt cerebrovascular injuries: analysis of
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35. Rozycki GS, Ballard RB, Feliciano DV, et al. Surgeon-
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74
Management of Thoracic Trauma
David T. Efron, MD and
Edward E. Cornwell III, MD
INTRODUCTION
As with all traumatic injury, the management of thoracic
trauma is centered on both the rapid diagnosis and the
correction of the insult. Particular to injuries to the chest
is the possible simultaneous disruption of two of the three
life-sustaining physiologic processes (namely, breathing
and circulation). Therefore, life-saving treatment and
diagnosis often must occur in congruity. Many of the
pitfalls that present themselves in the management of
thoracic trauma are mistakes of omission and carry the risk
of extreme morbidity and mortality. Many of the physi-
ologic principles apply in the management of both blunt
and penetrating injuries. As such, specic injuries are
addressed in this chapter rather than mechanism.
The steps followed in the care of the traumatically
injured patient are well described and outlined by the
Advanced Trauma Life Support training put forth by
the Committee on Trauma of the American College of
Surgeons.1 Ensuring an airway and conrming effective
breathing and circulation are prime goals and permit
appropriate diagnosis and guide treatment options.
INDICATIONS
Hypotension
Chest wall defects (open or closed)
Injury mechanism
MANAGEMENT OF THORACIC
TRAUMA STEPS
Step 1 Airway
Step 2 Breathing
Step 3 Circulation
Step 4 Disability
Step 5 Exposure
On arrival at the trauma bay, once an airway is deemed
secure, the lung elds are auscultated with a stethoscope.
Absence of breath sounds suggests loss of pulmonary
aeration and is likely due to collapse of the pulmonary
parenchyma and replacement with air, blood, or abdomi-
nal contents owing to diaphragmatic rupture (very rare on
the right). Adjunctive physical examination ndings may
aid in the cause of pulmonary collapse such as tracheal
shift from midline, hyperresonance (pneumothorax), or
dullness (hemothorax) to percussion. However, in a busy,
loud trauma room, these are rarely discernible. Victims of
penetrating trauma will have wounds that will aid in iden-
tication of potential injury and that must be sealed as
a source of pleural air. Accompanying hypotension may
suggest tension physiology, which requires immediate
decompression either by placement of a large-bore intra-
venous catheter into the pleural space (via the second
intercostal space in the midclavicular line) or by immedi-
ate chest tube placement if it is readily available. Chest
radiograph as an adjunct to the primary survey is often
helpful in identifying hemo- or pneumothorax in the
hemodynamically stable patient.
Incomplete Pleural Decompression of
a Pneumothorax
Consequence
Because victims of thoracic trauma are at risk of mul-
tiple injuries contributing to the overall picture, accu-
rate diagnosis and treatment are vital. An inadequately
performed decompression of a tension pneumothorax
not only continues the circulatory embarrassment of
the patient but also confuses the picture and may delay
vital diagnostic and therapeutic decision making. The
thoracic cavity may be entered in the initial attempt at
tube placement, thereby relieving the immediate tension
pneumothorax. However, if the tube is subsequently
left in the subcutaneous space, the tension may reac-
cumulate owing to ongoing leak from the pulmonary
parenchyma.
Grade 4/5 complication
Repair
Replacement of the intravenous catheter. Replacement
of a subcutaneous chest tube.
 774 SECTION XII: TRAUMA SURGERY

Prevention
Intravenous decompression: The apex of the thoracic
cavity at the level of the second rib slopes posteriorly,
though the chest wall in most patients remains parallel
to the oor in the supine patient. To properly position
this catheter, it is angled in a caudal direction and
passed over the third rib.
Chest tubes: This is often identied at postprocedure
chest x-ray. Making the skin directly over the sixth rib at
the point at which the tube is intended to enter the tho-
racic cavity and not trying to tunnel the chest tube helps
avoid subcutaneous placement and ensure correct posi-
tioning. Obese patients are particularly at risk.

Incomplete Decompression of a Hemothorax

Consequence
Persistent hypotension after appropriate treatment of
Figure 741 This patient suffered multiple rib fractures on the
tension pneumothorax suggests an alternative ongoing
left after a motor vehicle collision. Initial chest tube placed for a
source of shock. Massive hemothorax with ongoing pneumothorax was kinked at the most distal hole. Persistent pneu-
bleeding is a well-recognized indication for operative mothorax is evident at the left apex on the chest x-ray.
intervention. Unrecognized persistent hemothorax at
minimum hinders respiratory status, but more worri-
some is the failure to recognize the source of ongoing
hemorrhage and basing decision making on incomplete
or faulty data (i.e., unnecessary laparotomy or delayed
thoracotomy). This may be due to ongoing thoracic
bleeding or improper positioning or kinking of the
chest tube.
Grade 3/4 complication
Repair
A postinsertion chest radiograph conrms positioning
of the chest tube. Recognition of a kinked chest tube
on x-ray leads the surgeon to reposition it appropriately
(Fig. 741). Clotted chest tubes can occur; however,
this scenario is often associated with massive hemotho-
rax and ongoing blood loss (Fig. 742).
Prevention
Insertion of a large-bore chest tube (36, 38, or 40 Fr)
allows for maximal drainage of blood in patients with
hemothorax. By twirling the chest tube around its lon-
Figure 742 This patient suffered a gunshot wound to the right
gitudinal axis while inserting it through the chest wall,
chest and presented with a hemopneumothorax. The persistent
one ensures that it is not kinked. This maneuver should
massive hemothorax can be seen despite the excellent position of
be performed whether the tube is inserted for hemo- two chest tubes.
thorax or pneumothorax.

Unrecognized Aortic Tear

In the absence of hemothorax, the approach to the man-
agement in this scenario depends upon whether the mech-
anism of injury is blunt or penetrating.
Patients suffering blunt injury of signicant force are
at elevated risk for aortic tear, most frequently seen just
distal to the left subclavian orice. Frequently, chest x-ray
evidence suggests signs of great vessel injury including
widened mediastinum, loss of the aortic knob, and pleural
capping.2 Other signs that indicate heightened energy
transfer include high rib fractures and sternal or scapular
fractures.
Consequence
The ultimate consequences of unrecognized aortic
injury include rupture and death. In addition, if the
rupture remains contained, subsequent thoracic aortic
aneurysm may develop.
Grade 4/5 complication
 74 MANAGEMENT OF THORACIC TRAUMA
Repair
Acute thoracic aortic disruption requires repair, most
frequently with short segment graft interposition.
Despite some case reports, there is not consistent
enough experience to recommend an attempt at endo-
vascular repair outside major study centers.3,4
Prevention
Aggressive work-up and recognition of these injuries
are mandatory. The gold standard has traditionally
been conventional aortography. However, thoracic
computed tomography (CT) scan has been shown to
be reliable. Transesophageal echocardiography, when
available, is another potential alternative.
Unrecognized Abdominal Injury
Complication
Hypotension in the setting of blunt aortic injury must
be ascribed to another source of shock. Noncontained
aortic tears result in rapid demise from exsanguinating
hemorrhage. The blood found in the periaortic tissue
from a contained tear in and of itself is usually not
enough to cause global shock. Patients suffering suf-
cient blunt injury to incur aortic tear are also at risk for
multiple injuries including fractures and abdominal
injuries such as liver and splenic fractures. These inju-
ries are much more likely to be exsanguinating, espe-
cially in the time it takes to work up and treat the aortic
tear. Missed abdominal injury in this setting is poten-
tially lethal.
Grade 4/5 complication
Repair
Rapid exploratory laparotomy is the only solution if the
injury is recognized late.
Prevention
Aggressive screening is vital. In the hemodynamically
stable patient, CT scanning of the chest and abdomen
is integral to accurate injury diagnosis. Patients who are
hemodynamically unstable may undergo focused
abdominal ultrasound for trauma (FAST) or diagnostic
peritoneal lavage (DPL).5,6 The nding of intra-
abdominal uid in this setting necessitates immediate
laparotomy prior to the denitive work-up for aortic
tear (which is undertaken immediately after the abdom-
inal injuries are stabilized).
Hypotension in the Setting of Penetrating
Thoracic Injury
Hypotension in the setting of penetrating thoracic injury
is due to bleeding, tension physiology, or cardiac tampon-
ade. Ongoing bleeding often requires immediate opera-
tive repair. Tamponade often results in patient arrest en
route to or immediately after arrival at the trauma bay.
When this occurs, emergency department thoracotomy is
775
warranted. The prime goals are to (1) release a tamponade
by opening the pericardium, (2) potentially control the
hemorrhagic source by direct pressure, and (3) ensure
adequate blood ow to the brain and coronary vessels by
applying an aortic cross-clamp. This is achieved via a left
anterolateral thoracotomy in the fth intercostal space.
When access to the thoracic cavity is gained, the pericar-
dium is opened.7,8
Delayed Transport to the Operating Room to
Allow Intubation
Consequence
In the setting of penetrating injury to the pulmonary
parenchyma, the relatively low-pressure pulmonary vas-
culature is directly exposed to the aerated regions
owing to the disruption of the architecture of each. In
the nonintubated patient, the bronchial tree is also a
low pressure system. When the patient is intubated,
positive-pressure ventilation often causes the bronchial
tree to become the higher-pressure system, especially
in the setting of deep hemorrhagic shock. This raises
the risk of air embolus.
Grade 4/5 complication
Prevention
Rapid transport to and intubation in the operating
room minimize the exposure time of the injured pul-
monary vessels to the potentially high positive-pressure
ventilation transmitted across injured airways. This also
minimizes the time to denitive surgical therapy.
Phrenic Nerve Injury
Consequence
Left hemidiaphragm paralysis.
Grade 2/3 complication
Prevention
As the phrenic nerve courses longitudinally along the
anterior aspect of the pericardium in the left hemitho-
rax, the nerve is identied and the opening in the
pericardium is made in a longitudinal manner parallel
to the course of the nerve.
Unrecognized Right Thoracic Injury
at Left Thoracotomy
Consequence
Missed thoracic injury in the right hemithorax signi-
cantly delays appropriate management and may lead to
a lethal delay.
Grade 4/5 complication
Prevention
For penetrating injuries to the chest, especially in the
case of multiple injuries and suspected transmediastinal
trajectory, simultaneous right chest tube placement at
the time of left thoracotomy is advisable.
 776 SECTION XII: TRAUMA SURGERY
Figure 743 Barium enema study of a patient with herniation of
his colon through the left diaphragm. The defect is a result of a stab
wound to the left lower chest several years prior.
Other Issues
Unrecognized Diaphragm Injury
Consequence
Forty percent of penetrating thoracoabdominal wounds
demonstrate associated diaphragm injury.9 Over time,
left hemidiaphragm lacerations are at risk for develop-
ing into diaphragmatic hernias (Fig. 743). The right
side is well protected by adhesion to the dome of the
liver.
Grade 2/3 complication
Repair
Subsequent operative takedown of a transdiaphragm
hernia and repair are required.
Prevention
We favor an aggressive approach to penetrating injuries
to this region. Any patient suffering a penetrating injury
to the left thoracoabdominal region (from the sternum
at or below the level of the nipple around to the scap-
ular tip posteriorly and inferiorly to the costal margins)
is taken for exploratory laparoscopy to inspect the dia-
phragm (Fig. 744). Injuries may be repaired in an
open manner or laparoscopically if the surgeon is con-
dent that other intraperitoneal injury can be excluded.
Figure 744 Laparoscopic view of a diaphragmatic injury in a
patient suffering an isolated stab wound to the left lower chest
posteriorly. The Kelly clamp has been passed through the external
defect and denes the track of the injury.
It should be noted that up to 20% of diaphragmatic
injuries are present in the setting of a normal chest
radiograph.10
Inadequate Analgesia for Rib Fractures
Consequence
The force sustained during blunt injury required to
cause multiple rib fractures is often transmitted to the
underlying pulmonary parenchyma and results in pul-
monary contusion. This combination of pathology can
lead to severe respiratory embarrassment. The area of
contusion behaves as an intrapulmonary shunt demon-
strating perfusion without aeration. Early on postin-
jury, this physiology worsens as the contusion matures.
In addition, the patient will ineffectively breathe to
utilize the remaining pulmonary tissue because of the
pain associated with rib fractures. Analgesia is vital to
successful pulmonary toilet and maintenance of pulmo-
nary function. Inadequate analgesia can result in respi-
ratory failure with subsequent mechanical ventilation
and potential development of pneumonia.
Grade 2/3 complication
Prevention
Accurate recognition of the extent of the injury is key.
Patients may require intravenous patient-controlled
analgesia with narcotics combined with oral nonsteroi-
dal anti-inammatory agents. The Eastern Association
for the Surgery of Trauma guidelines recommend
that epidural anesthesia is the preferred method of
pain control for rib fractures from blunt injury (level 1
recommendation), that all patients over 65 with four
or more rib fractures should undergo placement of a
thoracic epidural for pain control, and consideration
of thoracic epidural anesthesia should be given to
 74 MANAGEMENT OF THORACIC TRAUMA
any patient with four or more rib fractures (level 2
recommendations).11
Retained Hemothorax
Consequence
Entrapped lung from brin peal formation and
empyema.
Grade 2/3 complication
Repair
Open thoracotomy for excision of brin peal and release
of entrapped lung. This is often a difcult procedure,
given the inammation, and is frequently accompanied
by moderate blood loss.12
Prevention
Plain chest radiographic imaging has a poor sensitivity
in predicting the absence or presence of a signicant
volume of retained pleural blood. The pulmonary
parenchyma is often contused, and this can suggest
uid where there is none or mask a signicant volume
of retained blood. A CT scan of the thorax enables
quantication of retained uid.13 If done within the
rst 4 days postinjury (prior to the formation of the
brin peal), a video-assisted thoracoscopic drainage of
the retained blood is usually successful and avoids the
need for thoracotomy and empyemectomy.14
REFERENCES
1. American College of Surgeons Committee on Trauma.
Advanced Trauma Life Support (ATLS) Student Course
Manual, 7th ed. Chicago: American College of Surgeons,
2004.
2. Nagy K, Fabian T, Rodman G, et al. Guidelines for the
diagnosis and management of blunt aortic injury. Eastern
Association for the Surgery of Trauma: Trauma Practice
Guidelines, 2001. Available at http://www.east.org/tpg/
chap8.pdf
777
3. Tehrani HY, Peterson BG, Katariya K, et al. Endovascular
repair of thoracic aortic tears. Ann Thorac Surg 2006;82:
873877.
4. Hoornweg LL, Dinkelman MK, Goslings JC, et al.
Endovascular management of traumatic ruptures of the
thoracic aorta: a retrospective multicenter analysis of 28
cases in The Netherlands. J Vasc Surg 2006;43:1096
1102.
5. Ma OJ, Gaddis G, Steele MT, et al. Prospective analysis of
the effect of physician experience with the FAST examina-
tion in reducing the use of CT scans. Emerg Med
Australas 2005;17:2430.
6. Von Kuenssberg Jehle D, Stiller G, Wagner D. Sensitivity
in detecting free intraperitoneal uid with the pelvic views
of the FAST exam. Am J Emerg Med 2003;21:476
478.
7. Branney SW, Moore EE, Feldhaus KM, Wolfe RE.
Critical analysis of two decades of experience with
postinjury emergency department thoracotomy in a
regional trauma center. J Trauma 1998;45:8794.
8. Hunt PA, Greaves I, Owens WA. Emergency thoracotomy
in thoracic traumaa review. Injury 2006;37:119.
9. Murray JA, Demetriades D, Asensio JA, et al. Occult
injuries to the diaphragm: prospective evaluation of
laparoscopy in penetrating injuries to the left lower chest.
J Am Coll Surg 1998;187:626630.
10. Murray JA, Demetriades D, Cornwell EE 3rd, et al.
Penetrating left thoracoabdominal trauma: the incidence
and clinical presentation of diaphragm injuries. J Trauma
1997;43:624626.
11. Pain management in blunt thoracic trauma (btt)an
evidence-based outcome evaluation. Eastern Association
for the Surgery of Trauma: Trauma Practice Guidelines
2004. Available at http://www.east.org/tpg/painchest.pdf
12. Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacua-
tion of retained posttraumatic hemothorax. Ann Thorac
Surg 2004;78:282285.
13. Velmahos GC, Demetriades D. Early thoracoscopy for the
evacuation of undrained haemothorax. Eur J Surg 1999;
165:924929.
14. Ahmed N, Jones D. Video-assisted thoracic surgery: state
of the art in trauma care. Injury 2004;35:479489.
75
Management of Pancreatic and
Duodenal Injuries
David T. Efron, MD and
Edward E. Cornwell III, MD
INTRODUCTION
The management of pancreatic and duodenal injuries is
often difcult, primarily owing to the unforgiving nature
of injured tissues in these organs. Damage to these struc-
tures is often associated with a high mortality, especially
with a penetrating mechanism, because of simultaneous
injury to major vascular and other intra-abdominal
structures.15 Appropriate management requires accurate
diagnosis of the injuries, a clear understanding of gastro-
intestinal physiology (with a plan for restoring disrupted
continuity), and acute attention to the ongoing status and
stability of the patient.
MANAGEMENT OF PANCREATIC AND
DUODENAL INJURIES STEPS
Step 1 Stabilization and diagnosis
Step 2 Complete exposure of duodenum and pancreas
(Kochers maneuver, exploration of lesser sac,
mobilization of spleen and pancreatic tail)
Step 3 Determination of resection, repair, drainage
Step 4 Repair (dependent upon injuries present)
OPERATIVE PROCEDURE
Stabilization and Diagnosis
Patients presenting with penetrating injuries that result in
pancreatic or duodenal injuries almost uniformly demon-
strate signs requiring immediate laparotomy. Hypotension
and abdominal distention indicative of excessive blood
loss are suggestive of major associated vascular injury. This
is the setting in which most patients are explored for and
the pancreatic and duodenal injuries must be suspected
and ruled out. To accomplish this, the entire trajectory
of the penetrating object must be assessed. Central retro-
peritoneal hematomas must be explored. In the hemody-
namically stable patient, peritonitis is often identied on
presentation and also warrants immediate exploration.
Victims of blunt abdominal trauma are often hemody-
namically stable, allowing for more substantial work-up
and diagnosis of injuries. Many patients present with
multiple injuries, the result of high-energy transfer, such
as motor vehicle collisions, pedestrians struck, or falls from
height. Other blunt mechanisms include focused-point
blows to the epigastrium with transmitted force directly
over the duodenum and pancreas (such as falling onto a
bicycle handle).6
Admission and serial serum amylase measurements can
be useful to guide a more focused investigation of pan-
creatic injury. However, serum amylase at presentation is
a poor predictor of pancreatic injury requiring operative
repair.7,8 Computed tomography scanning is useful because
it provides the most anatomic information with regards
to these injuries and can easily diagnose duodenal wall
hematomas, pancreatic fracture, peripancreatic edema or
hematoma, free extravasation of contrast from duodenal
disruption as well as associated trauma such as splenic or
hepatic fractures.4,5,9,10 However, isolated pancreatic injury
may not be evident at the time of initial scanning when
inammation may still be minimal. Focused abdominal
sonography for trauma (the FAST scan) clearly demon-
strates free intra-abdominal uid but cannot delineate a
specic source and is not useful for the diagnosis of ret-
roperitoneal injuries.
In the stable patient without peritonitis, more specic
diagnostic modalities are useful to assess for suspected
pancreatic and duodenal injuries. An upper gastrointesti-
nal contrast study with Gastrogran can identify both
luminal narrowing (the result of a duodenal mural
hematoma) and contrast extravasation.9 Esophagogastro-
 780 SECTION XII: TRAUMA SURGERY

duodenoscopy (EGD) with endoscopic retrograde chol-

angiopancreatography (ERCP) allows nonoperative
assessment of the integrity of both the main pancreatic
and the common bile ducts.11,12
Inappropriate Radiographic Work-up Delaying
Operative Intervention
Consequence
Delayed operative intervention for a patient with major
intra-abdominal hemorrhage is potentially life threat-
ening and can have highly morbid sequelae owing to
the need for resuscitation, excessive blood transfusion,
and risk of coagulopathy.
Grade 4/5 complication
Prevention
Adherence to the principles of trauma management
with recognition of the hard indications for abdominal
exploration facilitates rapid transport to the operating
room. Pancreatic and duodenal injuries in and of them-
selves are rarely a cause of hemodynamic instability.
When present, this is the result of other injuries, which
must be immediately addressed.

Complete Exposure of the Duodenum and

Pancreas (Kochers Maneuver, Exploration of
the Lesser Sac, Mobilization of the Spleen and
the Pancreatic Tail) Figure 751 Division of the connective tissue along the lateral
edge of the duodenum as the beginning of the Kocher maneuver.
The entire trajectory of the penetrating object must be
assessed, and central retroperitoneal hematomas must be
explored. Complete mobilization of the duodenum and
the head of the pancreas allows inspection and palpation
of the posterior aspect of these organs and the potential
injuries that may have resulted from a through-and-
through trajectory to this region. When the track of the
bullet traverses to the right of the superior mesenteric
artery and vein, complete mobilization of the second
portion of the duodenum and the head of the pancreas is
accomplished via an extensive Kocher maneuver. By
retracting the hepatic exure of the colon inferomedially,
the avascular connective tissue along the left lateral and
posterior borders of the duodenum is easily divided (Fig.
751). Often, the right colon must be mobilized from the
retroperitoneum along the line of Toldt to allow access to
this region. Care must be taken to remain close to the
duodenum and posterior pancreatic head because the infe-
rior vena cava, right renal veins, and Gerotas fascia are just
deep to this dissection. The mobilization is taken to the
lateral (right) edge of the superior mesenteric artery and
vein.
The anterior surface of the body and tail of the pancreas
is explored through the lesser sac. Access to the lesser sac
is best achieved through the gastrocolic ligament, initially
via the relatively avascular area to the left of the midline
toward the splenic exure. This provides a clear view of Figure 752 Exploration of the lesser sac demonstrates the
the anterior surface of the pancreas (Fig. 752). A hema- length of the anterior surface of the pancreas. A central hematoma
toma overlying the pancreas is explored (Fig. 753). is shown.
 75 MANAGEMENT OF PANCREATIC AND DUODENAL INJURIES
Figure 753 Hematoma overlying the pancreas is explored. The
inferior border of the gland is safely mobilized so that the posterior
aspect of the gland may be explored for injury.
The posterior aspect of the body and tail of the pancreas
is visualized either by dissection along the relatively avas-
cular plane at the lower border of the pancreas (see Fig.
753) or by the complete mobilization of the spleen and
pancreas medially out of the retroperitoneum (Fig. 754).
This aspect of medial visceral rotation is accomplished by
freeing the retroperitoneal attachments of the spleen from
along the diaphragm and Gerotas fascia and subsequently
elevating the pancreas from the retroperitoneum with the
splenic artery and veins intact. This allows inspection of
the posterior border of the pancreas for through-and-
through injury. The pancreas can be mobilized to the level
of the superior mesenteric vessels.
The Kocher maneuver allows inspection of the entire
C-loop of the duodenum. The rst, third, and fourth por-
tions are more easily directly inspected. If an anterior
injury is noted as a result of penetrating injury, a posterior
exit should be sought.
Missed Pancreatic or Duodenal Injury
Consequence
Failure to identify pancreatic injury may result in pan-
creatic leak, peripancreatic abscess, pancreatic stula,
pancreatitis, pseudoaneurysm formation, sepsis, and
pseudocyst formation.25,13 Similarly, failure to identify
duodenal perforation can result in local abscess, duo-
denocutaneous stula, and severe sepsis.1315 Each
carries elevated morbidity and mortality.
Grade 4/5 complication
781
Figure 754 Medial rotation of the spleen and pancreas from
the left retroperitoneum also allows access to the posterior aspect
of the gland and is the principal maneuver in completing a distal
pancreatectomy and splenectomy.
Repair
Control of leakage and wide drainage are the governing
principles to treatment of missed injuries. In all but a
very few stable patients, this includes reexploration for
appropriate treatment. Isolated pancreatic duct injuries
identied endoscopically may be treated with place-
ment of a pancreatic duct stent (Fig. 755).
Prevention
Complete mobilization of the duodenum and the head
of the pancreas allows inspection and palpation of the
posterior aspect of these organs and the potential inju-
ries that may have resulted from a through-and-through
penetrating trajectory to this region. Complete mobi-
lization of both the duodenum and the pancreas at the
time of laparotomy is also important in blunt trauma
in which there is suspicion of pancreatic or retroperi-
toneal duodenal injury.
Injury to a Replaced Right Hepatic Artery
during Kocherization
Consequence
In 10% to 15% of patients, a replaced right hepatic
artery is identied at the superior edge of the dissec-
tion.16 The difculty of this dissection is at times
 782 SECTION XII: TRAUMA SURGERY
increased by tissue hematoma from bleeding vessel
branches. If this is injured in the dissection, signicant
hepatic ischemia may ensue, especially if there is con-
comitant injury to the portal vein.
Grade 2/3 complication
Repair
If the right lobe of the liver demonstrates critical vas-
cular compromise owing to interrupted ow, arterial
bypass emergent may be necessary.17
Prevention
Careful palpation of a pulse in this vessel (if present)
denes the superior limit of the Kocherization and
avoids injury to this vessel.
Determination of Drainage, Repair,
or Resection
The decision to proceed with a complex gastrointestinal
reconstruction in this acute setting will invariably lead to
exacerbation of the lethal triad of hypothermia, coagu-
lopathy, and acidosis with subsequent patient demise.18
Hemodynamic Instability, Acidosis,
Hypothermia, Coagulopathy
Consequence
Death.
Grade 4/5 complication
Prevention
Control of hemorrhage and intestinal spillage and tem-
porary abdominal closure with transport to the inten-
sive care unit for correction of the previously described
physiologic perturbations are the only life-sustaining
options. Interval return to the operating room to rees-
tablish gastrointestinal continuity is undertaken when
the patient is more stable.1,2
Pancreas
Complete exposure of the injury to the pancreas allows
assessment for main pancreatic duct injury. The integrity
of this duct guides operative decision making. Because the
Figure 755 Endoscopically placed pancreatic
duct stent for successful isolation of traumatic pan-
creatic duct disruption.
pancreatic duct is not easily identied in a normal gland,
this is not always easily accomplished by inspection alone.
Intraoperative uoroscopic pancreatography (either endo-
scopic or transduodenal) aids in identifying duct disrup-
tion for the hemodynamically stable patient. Because
neither the pancreatic duct nor the pancreatic parenchyma
are well managed with primary repair, pancreatic duct
disruption often necessitates pancreatic resection.
Injury to the duct at the neck, body, and tail of the
pancreas is well treated with a distal pancreatectomy. In
patients with a normal gland prior to injury, up to an 80%
distal pancreatectomy may be well tolerated without sub-
sequent endocrine or exocrine insufciency.19 This may be
performed either with or without splenic preservation. If
splenic preservation is opted for, careful dissection is nec-
essary to ligate the numerous splenic arterial and venous
branches found along the superior border of the pancreas
(Fig. 756).
Injury to the pancreatic parenchyma in the absence of
main duct injury is best treated with wide drainage with
closed suction drains placed at the time of exploration.
These serve well to control the pancreatic stulas reported
in as many as 15% of cases.25
Failure to Identify the Pancreatic Duct
Consequence
High-output pancreatic stula, metabolic acidosis, exo-
crine insufciency.
Grade 2/3 complication
Repair
Although consistent data are lacking for the denitive
treatment of pancreatic stulas, a number of options
exist for control of the stula. Strict nothing-by-mouth
status with total parenteral nutrition decreases the stim-
ulus of pancreatic exocrine function. The addition of
subcutaneous octreotide (100 mcg three times per day)
may also help, although prospective, randomized, con-
trolled studies of octreotide use in elective pancreatic
surgery provide conicting evidence.2024 ERCP may be
useful in identifying a proximal pancreatic duct stricture
the stenting of which may improve appropriate enteric
 75 MANAGEMENT OF PANCREATIC AND DUODENAL INJURIES
Figure 756 Careful dissection and ligation of the multiple vas-
cular branches along the superior edge of the pancreas allow the
option of splenic preservation in the course of distal pancreatec-
tomy for signicant injury to the distal body and tail of the gland.
ow of pancreatic juice. Occasionally, persistent stula
necessitates distal pancreatectomy (or revision distal
pancreatectomy), or roux-en-Y pancreatoenterostomy
(to the leaking distal pancreas) to control. Exocrine
insufciency is well treated with oral pancrelipase sup-
plementation, whereas bicarbonate replacement for
severe cases may also be provided via the oral route.
Prevention
Identication of the pancreatic duct and directed liga-
tion at the time of distal pancreatectomy reduce the
incidence of major leak.
Duodenum
The management of penetrating injury to the duodenum
is governed by the percentage of bowel wall involvement.
Disruption of greater than 50% of the duodenal circumfer-
ence precludes primary repair. Alternatively, these injuries
can be repaired with direct patching via a jejunoduode-
nostomy (either a loop or a roux). If the patient is hemo-
dynamically unstable, simple control of soilage is achieved
as part of a damage control procedure, and denitive
reconstruction is delayed. Extensive tissue destruction or
complete disruption of the distal common bile duct result-
ing from combined pancreaticoduodenal trauma may
require resection of the second portion of the duodenum
and pancreatic head via a pancreaticoduodenectomy. This
783
may also be necessary to achieve hemorrhage control. As
previously noted, in hemodynamically unstable patients,
reconstruction of gastrointestinal continuity can be delayed
until the patient is adequately resuscitated.
Failure to Identify the Course of the Common
Bile Duct in the Head of the Pancreas or the
Ampulla at the Duodeum
Consequence
Suture ligation of the common bile duct with complete
biliary obstruction.
Grade 3/4 complication
Repair
Endoscopic transampullary imaging with endoscopic
stent placement is possible for incomplete transection
and incomplete ligation of the common bile duct. This
may not be optimal in a patient with a fresh duodenal
repair and suture line. A percutaneous transhepatic
biliary drain can often be threaded across such a biliary
structure. However, in the case of suture ligation, this
is technically quite difcult. This may result in complete
external drainage of biliary ow. In such cases, delayed
choledochoenterostomy or hepaticoenterostomy is
undertaken several months after recovery from the
acute injury.
Prevention
At the time of initial exploration, the ampulla may be
identied through the duodenal injury and a probe or
dilator passed into the bile duct to guide the placement
of repair sutures to avoid iatrogenic injury. If the
ampulla cannot be identied in this manner, a chole-
cystectomy may be performed with passage of a cath-
eter distally into the duodenum to identify both the
common bile duct and the ampulla itself, again facilitat-
ing repair.
Repair (Dependent upon Injuries Present)
The principles in the management of complex combined
pancreatic and duodenal injuries include maintenance of
enteric, pancreatic, and biliary ow; abundant drainage of
all injuries; and repairs and isolation of injured and repaired
tissue by diversion of the enteric stream. In addition to
repair of the duodenal injury (either primary or patched)
and drainage of the pancreatic parenchymal injury, the
pylorus is surgically closed (pyloric exclusion), either by
suture or by staples applied across the muscle, with addi-
tional creation of a gastrojejunostomy. Remarkably, the
pylorus is often patent at 4 to 6 weeks regardless of the
method of closure. At the time of repair, a feeding jeju-
nostomy is fashioned to assist in postoperative enteral
feeding should a pancreatic or proximal duodenal leak
form precluding oral-enteral alimentation. Some surgeons
add a retrograde intraluminal drainage tube to assist in
enteric decompression.2,14,15
 784 SECTION XII: TRAUMA SURGERY
Inadequate Pyloric Exclusion
Consequence
Inadequate isolation of injured duodenal segment. If
sutures are placed in a prepyloric location, isolated
distal gastric antrum is excluded from exposure to
acid-losing feedback inhibition. This results in hyper-
secretion of gastrin, subsequent hyperacidity and
potential for gastritis, and marginal ulceration at the
gastrojejunostomy.25
Grade 2/3 complication
Repair
In the short-term, proton pump inhibitors may aid this.
Sutures may potentially be cut endoscopically, but
stapled exclusion is not amenable to this. Surgical revi-
sion is reserved for intractable cases.
Prevention
Appropriate identication of the pylorus ensures correct
placement of the exclusion. Internal digital palpation
of the pylorus via a gastrostomy greatly facilitates
correct identication.
REFERENCES
1. Rickard MJ, Brohi K, Bautz PC. Pancreatic and duodenal
injuries: keep it simple. Aust N Z J Surg 2005;75:581
586.
2. Lopez PP, Benjamin R, Cockburn M, et al. Recent trends
in the management of combined pancreatoduodenal
injuries. Am Surg 2005;71:847852.
3. Vasquez JC, Coimbra R, Hoyt DB, Fortlage D. Manage-
ment of penetrating pancreatic trauma: an 11-year
experience of a level-1 trauma center. Injury 2001;32:
753759.
4. Patton JH, Fabian TC. Complex pancreatic injuries. Surg
Clin North Am 1996;76:783795.
5. Patton JH Jr, Lyden SP, Croce MA, et al. Pancreatic
trauma: a simplied management guideline. J Trauma
1997;43:234239.
6. Jacombs AS, Wines M, Holland AJ, et al. Pancreatic
trauma in children. J Pediatr Surg 2004;39:9699.
7. Shilyansky J, Sena LM, Kreller M, et al. Nonoperative
management of pancreatic injuries in children. J Pediatr
Surg 1998;33:343349.
8. Jobst MA, Canty TG, Lynch FP. Management of pancre-
atic injury in pediatric blunt abdominal trauma. J Pediatr
Surg 1999;34:818824.
9. Degiannis E, Boffard K. Duodenal injuries. Br J Surg
2000;87:14731479.
10. Cornwell EE, Campbell K. Operative management of
pancreatic trauma. In Baker RJ, Fischer JF (eds): Mastery
of Surgery, 4th ed. Baltimore: Lippincott Williams &
Wilkins, 2001; pp 13191325.
11. Varadarajulu S, Noone TC, Tutuian R, et al. Predictors of
outcome in pancreatic duct disruption managed by
endoscopic transpapillary stent placement. Gastrointest
Endosc 2005;61:568575.
12. Wolf A, Bernhardt J, Patrzyk M, Heidecke CD. The value
of endoscopic diagnosis and the treatment of pancreas
injuries following blunt abdominal trauma. Surg Endosc
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13. Tyburski JG, Dente CJ, Wilson RF, et al. Infectious
complications following duodenal and/or pancreatic
trauma. Am Surg 2001;67:227230.
14. Timaran CH, Martinez O, Ospina JA. Prognostic factors
and management of civilian penetrating duodenal trauma.
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16. Covey AM, Brody LA, Maluccio MA, et al. Variant
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17. Samek P, Bober J, Vrzgula A, Mach P. Traumatic
hemobilia caused by false aneurysm of replaced right
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18. Loveland JA, Boffard KD. Damage control in the
abdomen and beyond. Br J Surg 2004;91:10951101.
19. Slezak LA, Andersen DK. Pancreatic resection: effects on
glucose metabolism. World J Surg 2001;25:452
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20. Hesse UJ, De Decker C, Houtmeyers P, et al. Prospec-
tively randomized trial using perioperative low dose
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jejunostomy. Acta Chir Belg 2005;105:383387.
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tic octreotide decrease the rates of pancreatic stula and
other complications after pancreaticoduodenectomy?
Results of a prospective randomized placebo-controlled
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22. Lowy AM, Lee JE, Pisters PW, et al. Prospective, random-
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pancreaticoduodenectomy for malignant disease. Ann Surg
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23. Montorsi M, Zago M, Mosca F, et al. Efcacy of octreo-
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24. Buchler M, Friess H, Klempa I, et al. Role of octreotide
in the prevention of postoperative complications following
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technique for pyloric exclusion. J Trauma 1998;45:593
596.
76
Traumatic Brain Injury
Adil H. Haider, MD and
Edward E. Cornwell III, MD
INTRODUCTION
Traumatic brain injury (TBI) is one of the most signicant
trauma diseases of our time, with an estimated annual
incidence of 1.4 million cases per year in the United
States. These injuries result in upward of 50,000 deaths
and 80,000 to 90,000 patients with lifelong or long-term
disabilities each year.1,2 It is estimated that 5.4 million
Americans are disabled owing to TBI, and the direct and
indirect costs associated with this problem exceeded $50
billion dollars annually by 1995.3
Little can be done to reverse the initial traumatic insult
and the resultant primary brain injury. However, second-
ary brain injury caused by decreased perfusion of the brain
tissue can be prevented and is, therefore, the most impor-
tant aspect in TBI management. Secondary injury is com-
monly a consequence of hypotension, hypoxia, or both.
In a study of the Trauma Coma Databank,4 mortality rose
from 25% to 75% if patients were subjected to both of
these factors (Table 761).
Guidelines for management of TBI have been developed
by the Brain Trauma Foundation (BTF) and the American
Association for Neurological Surgery (AANS), using the
best available evidence.5 These guidelines use the follow-
ing terminology: standards for level 1 recommenda-
tions, guidelines for level 2, and options for level 3.
The guidelines have three standards that recommend
against the use of certain previously practiced therapeutics
including (1) hyperventilation, (2) use of steroids after
head injury, and (3) prophylactic use of antiseizure med-
ications to prevent late seizures. This chapter presents
common TBI scenarios with management recommenda-
tions based on BTF/AANS guidelines.
SCENARIO 1
A 27-year-old man, nonhelmeted rider of a motorcycle is
brought to the emergency department after colliding with
a stationery vehicle. The paramedics report that the patient
initially complained of something wrong with my head
and now is verbalizing words that do not make any sense.
On primary survey, his airway is clear, he has bilateral
breath sounds, and his blood pressure is 101/61. Upon
painful stimuli, he opens his eyes and withdraws his
extremities, making incomprehensible sounds. The para-
medics suspect head injury, so the patient is immediately
transported to the computed tomography (CT) scanner.
The trauma team is concerned about intracranial hemor-
rhage, he may need to be rushed to the OR (operating
room), comments the trauma team leader. Upon arrival
at the CT scanner, the patient has agonal breathing
requiring emergent intubationand suffers several
minutes of desaturation.
Did not Intubate a Patient with a Glasgow Coma
Score of 8 or Less
Consequence
Emergent airway establishment leading to hypoxemia
and further brain injury.
Grade 3/4 complication
Prevention
In the ABCDs of resuscitation, D is for disability, or
quick neurologic examination with ascertainment of
the Glasgow Coma Score (GCS) (Table 762). This
patient has a GCS of 8 (eye opening [E] 2, verbal [V]
2, motor [M] 4). The two culprits most responsible for
secondary brain injury leading to death and disability
in TBI patients are hypoxia and hypotension. A patient
with GCS of 8 or less must be intubated to protect the
airway and prevent hypoxia. If endotracheal intubation
proves to be difcult and is not achievable quickly, a
cricothyroidotomy should be performed, and there
should be no hesitation in establishing a surgical airway
in trauma patients.
In this scenario, the trauma team had the correct sense
of urgency for obtaining the CT scan because the faster
the scan the faster the patient can be triaged to the oper-
ating room for an operable lesion. Once the airway is
secured and the primary survey is completed, a patient
with a GCS of 8 should receive a CT scan of the brain as
soon as possible to determine the extent of brain injury.
In these cases, valuable time should not be wasted per-
forming the secondary survey or doing routine procedures
such as placing a Foley catheter (Fig. 761).
 786 SECTION XII: TRAUMA SURGERY

Table 761 Outcomes after Secondary Brain Insult

TBI with GCS 3-8
among Patients with Traumatic Brain Injury
Secondary Insult (N) None to Moderate Death
Disability (%) (%)
Secure airway
Total patients (699) 43 37 (Intubation vs cricothyroidotomy)

Hypoxia (78) 45 33

Hypotension (113) 26 60 Complete primary survey

(Secure IV access, ensure HD stable)
Neither (456) 51 27

Hypotension and hypoxia (52) 6 75

Adapted from Trauma Coma Databank: Chesnut RM, Marshall LF, HD stable: Proceed to CT scan HD unstable: Continue
Klauber MR, et al. The role of secondary brain injury in determining Bypass secondary survey ATLS protocol
outcome from severe head injury. J Trauma 1993;34:216222.
Figure 761 Initial management of the traumatic brain injury
(TBI) patient. HD, hemodynamically.
Table 762 Glasgow Coma Score
Score Criterion

Eye Opening

4 Spontaneous

3 To verbal command

2 To pain

1 None

Motor

6 Obeys commands

5 Localizes pain

4 Withdraws to pain

3 Abnormal exion to pain (decorticate)

2 Abnormal extension to pain (decerebrate)

1 None

Verbal

5 Oriented and converses

4 Confused conversation

3 Inappropriate words

2 Incomprehensible sounds Figure 762 Computed tomography (CT) scan shows frontal
contusions without a midline shift.
1 None

Glascow Coma Score (GCS) = Eye opening + motor + verbal.

SCENARIO 2 scan of the head reveals frontal contusions without midline

A 52-year-old woman, restrained driver of a motor vehicle
is brought to the emergency department after a head-on
collision with another vehicle. Her heart rate is 65, blood
pressure is 97/54, and she has a peripheral oxygen satura-
tion of 97%. She is noted to make incomprehensible
sounds, has an abnormal exion of the limbs upon stimuli,
and opens her eyes only after being stimulated. She is
appropriately intubated to protect the airway. Initial CT
shift (Fig. 762). No other injuries are noted. Her blood
work is also within normal limits except for a mild base
decit on the arterial blood gas. The patient is slated to
be transferred to the intensive care unit (ICU) and is to
get a repeat CT scan in 8 hours. After a delay owing to
bed availability, the patient arrives at the trauma ICU 3
hours later. The admitting nurse notes that the patient has
xed and dilated pupils and now has a heart rate of 54
and blood pressure of 194/107.

Box 761 Risk of Intracranial Pressure Elevation
and Progression to Coma according to GCS
Mild TBI (GCS 1315) < 3%
Moderate TBI (GCS 912) = 10%20%
Routine ICP monitoring in these patients not indicated.
Severe Head Injury (GCS 8) and *Abnormal CT Scan
= 50%60%
Place ICP monitor.
Severe Head Injury (GCS 8) and Normal CT = 13%
In a patient with a normal CT, if any two of the following three
factors are present: age >40 years; systolic blood pressure
<90 mm Hg on admission; posturing then the risk of ICH is
similar to that of a patient with an abnormal head CT. In such
cases, an ICP monitor should be placed.
*Abnormal CT scan includes hematomas, contusions, edema,
compressed basal cisterns, and so on.
CT, computed tomography; GCS, Glascow Coma Score; ICH,
intracranial hemorrhage; ICP, intracranial pressure; TBI, traumatic
brain injury.
Did not Insert Intracranial Pressure Monitor
for a Patient with a High Risk of
Intracranial Hypertension
Consequence
Missed rising intracranial hypertension (ICH) leading
to brain herniation.
Grade 4/5 complication
Prevention
The BTF/AANS has clear guidelines suggesting inser-
tion of an intracranial pressure (ICP) monitor in patients
with increased risk for intracranial hypertension (ICH)5
(Box 761). Although a ventriculostomy offers the
added therapeutic advantage of being able to drain
cerebrospinal uid, it frequently is technically difcult
to place in patients with cerebral edema and com-
pressed ventricles. A beroptic catheter placed directly
into the brain parenchyma provides the most rapid ICP
monitoring access.
SCENARIO 3
A 73-year-old man with a past medical history of hyper-
tension, chronic renal insufciency, and alcohol abuse falls
off a stool in a bar and suffers a subdural hematoma 6 mm
in size without any midline shift. The patient has a GCS
of 13 and is admitted to the trauma ICU for close neu-
rologic observation. The patient becomes somewhat bel-
ligerent, trying to take off his C-spine collar and moving
his legs out of the bed. With the ICU staff suspecting
alcohol withdrawal, the patient is given a 2-mg dose of
lorazepam. The treating physician also notes that the
patient has a blood pressure of 180/80 mm Hg with a
76 TRAUMATIC BRAIN INJURY 787
Box 762 Calculation of Cerebral Perfusion
Pressure, (CPP)
Cerebral perfusion pressure (CPP) = Mean arterial pressure
(MAP) Intracranial pressure (ICP)
pulse of 53. He treats this hypertension with 10 mg of
hydralazine because the heart rate was only in the 50s.
The physician returns 2 hours later to assess the patient
after being informed that the vital signs had not changed
and the patient was now fast asleep. He nds the patient
to be unresponsive with a dilated left pupil.
Not Recognizing Changes in Mental Status
due to Raised ICP, even when Cushings Signs
Are Present
Consequence
Missed rising ICH leading to brain herniation.
Grade 4/5 complication
Prevention
The cerebral perfusion pressure (CPP) (Box 762) is
the difference between the mean arterial pressure
(MAP) and the ICP. The injured brain has minimal
room to expand because it is contained in the cranium,
a xed space. Hemorrhage or space-occupying lesions
increase the ICP from its normal value of 1 to
10 mm Hg at the expense of CPP. ICPs above 20 to
25 mm Hg should be treated. As depicted in Box 76
2, a rise in the ICP results in decreased CPP, which for
adults must be maintained over 70 mm Hg. In the
previous scenario, initial increases in ICP, manifested
by changes in neurologic status, were not noticed. The
patient then starts to exhibit Cushings triad (hyperten-
sion, bradycardia, and widening pulse pressure), an
ominous presentation suggesting markedly raised ICPs
and impending or concurrent ccerebral herniation
(Fig. 763).
SCENARIO 4
A 37-year-old woman construction worker falls off a scaf-
folding to the ground 20 feet below. She is intubated in
the eld and resuscitated in the emergency department,
where she is labeled as a transient responder to uids. Her
work-up reveals bilateral open lower extremity fractures,
a grade 3 splenic laceration for which her splenic artery is
embolized, and a single sided hemopneumothorax for
which a chest tube is placed. She has a GCS of 7, and a
CT reveals subarachnoid hemorrhage with multiple cere-
bral contusions, which are nonoperative. An ICP monitor
is placed, and her initial ICPs are in the 10 to 12 mm Hg
range. In the ICU, the patients ICP rises to 24 mm Hg
and the CPP is now only 48 mm Hg. To treat this, a 100-
mg bolus of mannitol is administered and a continuous
infusion of mannitol is also started. The patient immedi-
 788 SECTION XII: TRAUMA SURGERY

TBI with GCS 8

ICP monitor placed

Maintain CPP 70

Elevate head of bed to 30 Raise MAP 90

Reverse Trendelenburg for if adequately
spinal precaution patients volume hydrated

ICPs still elevated; CPP 70

Mannitol bolus Hypertonic saline

0.5 mg/kg Q 6 hourly 3% infusion or 26% bullet

If ICP still elevated consider using acute

hyperventilation for short periods only

If ICP remains high consider secondary methods:

Phenobarbitol comadecreases intracerebral metabolism Figure 764 Subdural hematoma with a midline shift.
Decompressive craniectomy

Figure 763 Schema for treatment of elevated intracranial
pressure.
ately starts to make a large volume of urine along with
further dropping her MAP to 58 mm Hg. In an effort
to avoid giving uids and minimize the probability of
further intracerebral cellular swelling, she is started on a
phenylephrine infusion to elevate her MAPs and keep her
CPP in the 70s because that is where the guidelines need
her to be.
Giving Osmotic Diuretics and Pressors to a
Hypovolemic Trauma Patient
Consequence
Decreased perfusion to body tissues, further exacerbat-
ing shock.
Grade 2/3 complication
Prevention
A CPP of at least 70 mm Hg should always be main-
tained in TBI patients, according to the BTF/AANS
guidelines.5 In some circumstances, this is done by
elevating the MAP to above 90 mm Hg with the help
of vasopressors. However, this should be done only
when hypovolemia has been ruled out. As with any
trauma resuscitation, hypovolemia must be alleviated
with the judicious use of uids. (Normal saline is com-
monly used because glucose-containing solutions are
avoided in TBI.) Similarly, diuretics should be given
only to patients with adequate volume on board. Man-
nitol, an osmotic diuretic, works by decreasing blood
viscosity and decreasing the diameter of peripheral
blood vessels, which helps maintain cerebral blood
ow. It also shifts water from the intracellular to intra-
vascular compartments, preventing cellular edema. This
effect lasts 6 hours, which is the reason for redosing at
6 hours. BTF/AANS guidelines also address the use of
hypertonic saline in trauma patients with brain injury,
identifying it as an option in which the goal is to
achieve hyperosmolar euvolemic resuscitation.
SCENARIO 5
A 65-year-old man is a restrained passenger in a minivan
that overturns. He suffers a subdural hematoma (Fig.
764), which is surgically evacuated. However, he still has
increased ICPs, which are treated with mannitol, hyper-
tonic saline, and ventriculostomy drainage. By postopera-
tive day 2, his ICPs are under control but he is still
unresponsive.
Even though the mannitol infusions have been stopped,
the patient continues to make copious amounts of urine,
4 L over 12 hours. He becomes tachycardic and is initi-
ated on -blockers. In addition, his serum sodium contin-
ues to rise, which is ascribed to the previous use of

hypertonic saline. Subsequently, the patients MAP
decreases and he starts to have seizures. His serum sodium
is found to be 172 mEq/L.
Ignoring the Signs of Diabetes Insipidus
Consequence
Decreased perfusion to body tissues, electrolyte imbal-
ances, and future neurologic impairment.
Grade 2/3 complication
Prevention
TBI patients, especially those who have had severe
enough injury to warrant an operation, have a signi-
cantly high incidence of central diabetes insipidus. In
this disorder, antidiuretic hormone (ADH) secretion
is decreased, leading to excessive, dilute urine pro-
duction. If not treated, this disorder may lead to
hypovolemia and, as in the case described previously,
hypernatremic seizures. Treatment is by replacing the
uid losses and administration of desmopressin, a 2-
amino acid substitute of ADH that has potent antidi-
uretic but no vasopressor activity.
76 TRAUMATIC BRAIN INJURY 789
REFERENCES
1. Langlois JA, Rutland-Brown W, Wald M. The epidemiol-
ogy and impact of traumatic brain injury: a brief overview.
J Head Trauma Rehab 2006;21:375378.
2. Thurman D, Alverson C, Dunn K, et al. Traumatic brain
injury in the United States: a public health perspective.
J Head Trauma Rehabil 1999;14:602615.
3. Thurman D. The epidemiology and economics of head
trauma. In Miller L, Hayes R (eds): Head Trauma: Basic,
Preclinical, and Clinical Directions. New York: Wiley &
Sons, 2001; pp 376388.
4. Chesnut RM, Marshall LF, Klauber MR, et al. The role of
secondary brain injury in determining outcome from severe
head injury. J Trauma 1993;34:216222.
5. Bullock MR, Chesnut R, Ghajar J, et al. Guidelines for the
surgical management of traumatic brain injury. Neurosur-
gery 2006;58(3 suppl):S2-1S2-3.
77
Managing Injuries to the Spleen
Adil H. Haider, MD and
Edward E. Cornwell III, MD
INTRODUCTION
Management of splenic injuries, whether iatrogenic or
traumatic, has one common principle: Never jeopardize a
patients life in an attempt to preserve the spleen; some
patients with splenic injury are best served by an expedi-
tious splenectomy. This chapter describes common pitfalls
in the operative management of the injured spleen along
with a discussion about nonoperative management (NOM)
of traumatic splenic injuries.
The decision to save rather than remove an injured
spleen requires consideration of the clinical presentation
of the patient. Splenic salvage should not be attempted
in an unstable patient with signicant injuries. Similarly,
a patient who has an iatrogenic injury to the spleen during
a complex abdominal surgery for cancer may not be a
candidate for splenorrhaphy. If splenic repair inordinately
prolongs the trauma laparotomy or requires the transfu-
sion of 2 or more units of packed red blood cells, splenor-
rhaphy should be aborted and a splenectomy should be
performed.
Attempting Splenorrhaphy without Adequate
Mobilization/Exposure
Consequence
Attempting to repair an incompletely mobilized spleen
is a frustrating exercise for both the surgeon and the
assistant. Struggling in the operative eld usually leads
to increased surgical complications; it also may further
increase blood loss.
Grade 2/3 complication
Repair/Prevention
Division of the avascular ligaments (lienophrenic, lieno-
renal, and lienocolic) is essential in mobilizing the
spleen medially out of its bed and up into the operative
eld close to the midline position of its embryologic
origin (Fig. 771). Once the spleen is mobilized and
assessed, hemostasis may be achieved by a combination
of topical hemostatic agents such as microbrillar col-
lagen (e.g., Avitene), methylcellulose (e.g., Surgicel),
or mattress sutures (e.g., 3-0 Prolene) placed either
directly or over Teon pledgets.
Partial splenectomy may be selected when early liga-
tion of a branch of the splenic artery to a segment of the
spleen results in major progress toward hemostasis (Fig.
772). Provided that 50% of the splenic parenchyma
attached to an identiable vessel is viable, partial splenec-
tomy may be performed and splenic immune function can
be expected to be maintained. Early demarcation of the
segment of the spleen to be removed with the electrocau-
tery device facilitates exposing intrasplenic vessels for indi-
vidual suture ligation, which should proceed meticulously.
Occasionally, cross-clamping the splenic hilum may be
temporarily required if manual compression does not
produce adequate hemostasis. The resected margin of the
spleen is then oversewn with mattress sutures with or
without pledgets (Fig. 773). If needed, a blunt liver
needle may be used to place such mattress sutures.
ADJUNCTS TO SPLENORRHAPHY
Argon Beam Coagulator
The argon beam coagulator (ABC) is an electrocoagula-
tion system that should not be confused with the argon
laser. No eyewear is required. The instrument achieves
hemostasis by using inert gas as a medium to conduct
radiofrequency energy (Fig. 774). The gas is emitted as
a constant ow at room temperature from a handpiece
and nozzle, which blows away blood and debris to opti-
mize visualization. The rst large clinical series utilizing
the ABC for splenic salvage was published in 1991.1 This
report concluded that most spleens with supercial lac-
erations are easily salvaged with standard topical maneu-
vers and that the ABC offers a technical advantage in
patients with deep parenchymal injuries. In the ensuing
decade, the ABC achieved wide acceptance in the manage-
ment of both spleen and other solid organ injuries.
Absorbable Mesh Wrap
Polyglycolic mesh wrap is another modality reported to
be useful in splenic salvage. The injured spleen is passed
through an enlarged hole in the mesh fashioned for this
purpose. The mesh is then wrapped around the spleen and
 792 SECTION XII: TRAUMA SURGERY

Lower pole
resected

Figure 772 To achieve hemostasis, the splenic artery branch to

Figure 771 After division of avascular ligaments, the spleen can the lower pole of the spleen is ligated. Subsequently, an anatomic
be mobilized medially, up into the operative eld, close to the resection of the lower pole of the spleen is performed. (Courtesy
midline position. (Adapted from Trunkey DD. Spleen. In Blaisdell of Corrine Sandone, MA, CMI 2007.)
FW, Trunkey DD [eds]: Trauma Management, Vol 1: Abdominal
Mattress sutures
Trauma. New York: Thieme, 1982; pp 149163.) placed through
pledgets

sutured to itself to provide tamponade (Figs. 775 and

776).2,3 More recent reports also suggested incorporat-
ing methylcellulose into the mesh to help bulk it up. In
this technique, multiple layers of methylcellulose are
placed directly onto the injured surfaces, after which
the mesh is secured around the spleen, enhancing the
tamponade effect. Previous concerns of possible mesh
infection, especially in the setting of hollow viscus injury,
have proved to be unfounded based on large series of
patients.4

Fibrin Glue
Early impressive laboratory experience with brin glue,
which consists of brinogen, dried thrombin, and calcium
chloride, prompted its emergence in the clinical area.
Commonly available brin sealants like Tisseal and
Crosseal may be applied directly to the injured surfaces of
the spleen to achieve immediate hemostasis, especially on
linear tears and cracks. Recent reports have demonstrated
application of brin sealants to glue together massively Figure 773 Manual compression and, if necessary, clamping of
injured spleens and then performing mesh splenorrhaphy. the splenic artery provide the hemostasis required to oversew the
Using this approach, grade 3 and 4 injured spleens have margin of the retained spleen. Teon pledgets are employed to
been salvaged.5 prevent suture from cutting through the otherwise friable tissue.
(Courtesy of Corrine Sandone, MA, CMI 2007.)
 77 MANAGING INJURIES TO THE SPLEEN 793

Argon beam
coagulation
of fractured
surface Figure 776 Mesh splenorrhaphy in situ with Surgicel placed
directly over the injured portion of the spleen, prior to suture-
securing the mesh. (Courtesy of Horacio A. Massotto, MD, Costa
Rica; reproduced with permission from www.trauma.org.)

Pancreatic Injury
Figure 774 Argon beam coagulator (ABC). (Courtesy of Consequence
Corrine Sandone, MA, CMI 2007.) The pancreatic tail is in close proximity to the splenic
hilum and is particularly prone to iatrogenic injury
during splenectomy, which may lead to a pancreatic
stula.
Grade 3/4 complication
Repair/Prevention
The pancreatic tail is in close proximity to the splenic
hilum and is particularly prone to iatrogenic injury
Spleen
passed during splenectomy. The splenic hilum and its vessels
through should not be clamped until the spleen is completely
hole in mobilized. After the splenic ligaments and the neces-
mesh
sary short gastric vessels are divided, the spleen is
brought upward and toward the midline, as described
in Figure 771. Upward traction elevates the spleen
away from the tail of the pancreas. In this position, the
spleen is attached only by the splenic artery and vein.
The artery should be taken rst by clamping it and then
dividing it close to the hilum. The splenic vein is very
delicate and should not be clamped. It is easier to just
tie it off in continuity as a nal step and then transect
Mesh gathered it at the hilum, delivering the spleen. If the procedure
posteriorly is unusually difcult or if pancreatic injury is consid-
Figure 775 Mesh splenorrhaphy. The injured spleen is passed ered, a drain should be left at the tail of the pancreas
through an enlarged hole in the mesh. The mesh is then wrapped to aid with long-term management of this injury.
around the spleen and sutured to itself. (Courtesy of Corrine
Sandone, MA, CMI 2007.)
Gastric Injury during Splenectomy
Consequence
Gastrocutaneous stula.
Grade 2/3 complication
 794 SECTION XII: TRAUMA SURGERY
Repair/Prevention
During splenectomy, the short gastric vessels must be
individually identied, isolated, and ligated toward the
spleen. Avoidance of injury to the stomachs fundus
and greater curvature is essential during this step. After
the short gastrics are taken, the greater curvature should
be inspected, and if there is any suspicion of compro-
mise, it must be repaired. This is commonly done by
inverting the suspect area and placing seromuscular
sutures with 2-0 or 3-0 silk. Ischemia or even a partial-
thickness gastric wall injury (e.g., owing to an electro-
cautery burn or by catching a portion of the gastric wall
while clamping the short gastrics) may lead to a gas-
trocutaneous stula.
LONG-TERM SEQUELAE
OF SPLENECTOMY
Not Administering Immunizations
after Splenectomy
Consequence
Overwhelming postsplenectomy infection.
Grade 3/4 complication
Prevention
The widespread acceptance of splenic salvage grows
from concerns for the physiologic risk of the asplenic
state, which includes possible susceptibility to nonfatal
infections as well as overwhelming postsplenectomy
infection (OPSI). OPSI is rare, with a reported preva-
lence of less than 0.5% in asplenic patients6; however,
it is lethal in adults, with a reported mortality in excess
of 50%. As a precautionary measure, patients who
get an elective splenectomy should be vaccinated
against three major encapsulated bacteriaStreptococcus
pneumoniae, Haemophilus inuenzae, and Neisseria
meningitidesprior to the procedure. Emergent sple-
nectomy patients should ideally recieve vaccines 2
weeks after the procedure to obtain the most substan-
tial immunological response. However, many trauma
surgeons, who fear losing a patient to follow-up,
administer vaccines just prior to discharge from the
hospital.
NOM OF SPLENIC TRAUMA
Continuing NOM in a Patient Requiring Multiple
Blood Transfusions
Consequence
Increased blood transfusions are independently associ-
ated with increased complications (especially infectious
complications) in trauma patients.
Grade 2/3 complication
Table 771 American Association for the Surgery of
TraumaOrgan Injury Scale for the Spleen
Grade* Injury Type Description of Injury
1 Hematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1 cm parenchymal depth
2 Hematoma Subcapsular, 10%50% surface area;
intraparenchymal, <5 cm in diameter
Laceration Capsular tear, 13 cm parenchymal
depth that does not involve a
trabecular vessel
3 Hematoma Subcapsular, >50% surface area or
expanding; ruptured subcapsular or
parenchymal hematoma;
intraparenchymal hematoma 5 cm or
expanding
Laceration >3 cm parenchymal depth or involving
trabecular vessels
4 Laceration Laceration involving segmental or hilar
vessels producing major
devascularization (>25% of spleen)
5 Laceration Completely shattered spleen
Vascular Hilar vascular injury with devascularized
spleen
*Advance one grade for multiple injuries up to grade 3.
From Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury scaling:
spleen and liver (1994 revision). J Trauma 1995;38;323324.
Repair/Prevention
At present, the proportion of patients with splenic inju-
ries managed nonoperatively has grown to over 70%,
owing to improvements in computed tomography
(CT) scanning technology as well as advancing tech-
niques in angioembolization of the spleen. The art of
NOM has been enhanced by the utility of the American
Association for the Surgery of Trauma (AAST)Organ
Injury Scale.7 The scale enables researchers and clini-
cians to make comparisons according to a standard
approach, aiding in therapeutic and research decisions
(Table 771).
Criteria for Patient Inclusion
Patients with blunt splenic injuries must meet the fol-
lowing criteria to be considered candidates for NOM:
(1) hemodynamic stability, (2) CT documentation and
classication of the injury, (3) absence on CT scan of
intra-abdominal (hollow viscus) or retroperitoneal (duo-
denum, pancreas, kidney) injuries mandating operative
intervention, and (4) transfusion of less than 2 units of
packed red blood cells (PRBCs) (Box 771). Restricting
transfusions to less than 2 units of PRBCs is extremely
important along with the known infectious risks associated
with blood transfusions. Compelling evidence now identi-
 77 MANAGING INJURIES TO THE SPLEEN
Box 771 Criterion for Nonoperative Management
of Blunt Splenic Injury
1 Hemodynamic stability
2 Documented computed tomography (CT) classication of
injury
3 Absence of additional injuries requiring operative
intervention
4 Transfusion of <2 units of packed red blood cells
es blood product transfusion as an independent risk
factor for complications in the injured patient.8 Other
exclusion criteria for NOM are patients in whom coagu-
lopathy cannot be reversed or those who need to be
anticoagulated urgently (e.g., a patient with an articial
heart valve or a trauma victim with blunt carotid injury
requiring anticoagulation).
The Particulars of NOM
In 2003, the Eastern Association for the Surgery of
Trauma (EAST)9 published practice management guide-
lines for patients with blunt liver or spleen injuries based
on best available evidence. Their level-two recommenda-
tions suggest that age, neurologic status, or associated
injuries do not preclude NOM in a hemodynamically
stable patient and that an abdominal CT scan is the most
reliable method to assess the severity of organ injury.
Level-three evidence suggests that this initial CT scan be
obtained with intravenous and oral contrast to enhance its
ability to delineate associated injuries.
The optimal success rate with NOM is obtained when
CT scanning is combined with careful serial clinical exam-
inations. Patients should be observed in a setting in which
serial physical examinations, vital sign readings, and hema-
tocrit determinations can be performed, and there should
be immediate operating availability in case clinical exami-
nation reveals an acute change. A suggested NOM scheme
for blunt splenic injury is depicted in Figure 777.
Angioembolization of the Splenic Artery
Initially described in 1995, angiography and embolization
of the splenic artery have become accepted adjuncts
for NOM in patients with blunt splenic injury.10 Routine
performance of an angiogram on all patients with splenic
injury has been found to be unnecessary, because very few
patients with grade 1 or 2 splenic injury require an inter-
ventional procedure. Earlier recommendations of per-
forming splenic angiography on all patients with contrast
pooling or a contrast blush on the initial CT scan have (1488 patients in 27 centers). In 2004, the AAST spleen
given way to greater emphasis on the grade of injury.11
Angiography of the splenic artery should be considered in
patients with grade 3 splenic injuries (Fig. 778) and
above and in patients with frank splenic artery hemorrhage
delineated on the initial CT scan. A multicenter study
performed under the auspices of the Western Trauma
795
Association (WTA)12 showed that grade of injury best
predicts the need for a vascular embolization procedure
(placement of coils or Gelfoam) and outcomes. In this
study with the adjunctive use of angioembolization pro-
cedures, more than 90% of patients with grade 3 splenic
injuries and 80% of patients with grade 4 and 5 splenic
injuries were successfully managed without an operation.
The study did not detect any differences between the types
of embolization material used (coils versus Gelfoam);
neither did it show any difference in success rates between
main splenic artery embolization and superselective embo-
lization techniques, in which the more distal splenic artery
segments are embolized. It also determined that the main
predictor of failure of angioembolization is the presence
of an arteriovenous stula on the initial CT scan. The
study also suggested that hemodynamically unstable
patients and older patients (age >55 yr) had a higher like-
lihood of failure of angioembolization.
Progression of Care
Studies are currently being performed to determine the
optimal time a patient receiving NOM should be kept on
nothing by mouth or on bedrest and when they should
be initiated on deep venous thromboembolism prophy-
laxis. Other questions under study are when such patients
can be safely discharged home and resume normal activity,
and whether or not they need follow-up radiographic
imaging for their splenic injury. In the meantime, surgical
intuition has been surveyed; a poll of EAST members
published in 200513 revealed that approximately 50% of
surgeons would recommend a patient with a grade 1 to 2
splenic injury return to light, normal activity at 2 weeks
and that they would not order a routine follow-up CT
scan for such patients. However, the same groups of
surgeons responded that they would recommend that a
patient with a higher-grade injury wait at least 4 to 6
weeks before resuming normal activities and would obtain
a follow-up CT scan. The physicians surveyed seemed to
be in agreement with level-three guidelines from EAST
that recommend obtaining a follow-up CT scan in patients
with grade 3 or higher splenic injuries, and in those
with high-risk occupations (e.g., athletes, construction
workers) before granting them medical clearance for
normal activity.
Success of NOM
A multi-institutional trial sponsored by EAST and pub-
lished in 200014 revealed a NOM success rate of 89%
study group15 reported a 96% success rate with NOM
(300+ patients). In children, the reported failure rate for
NOM is less than 2%. The most common cause for failure
of NOM is bleeding in the rst 96 hours. If the patient
becomes hemodynamically unstable, emergent splenec-
tomy is indicated. If the patient remains stable, a repeat
 796 SECTION XII: TRAUMA SURGERY

Abdominal
trauma

PRBC = packed red

blood cells
Hemodynamically Hemodynamically
stable unstable

CT scan revealing
splenic injury

Isolated low grade Contrast blush Injury requiring

splenic injury or grade III injury repair/resection

Success Consider arterial Fails

embolization

2448 hour
Peritonitis Operative
observation
Requires intervention
Monitor 2 units PRBC
Serial hemoglobins
Bedrest
Hemoglobin Hemodynamically
fails unstable

Stable
<2 units PRBC transfused
and
hemodynamically stable
Continue
observation
Hemoperitoneum
Repeat CT larger and/or active
bleeding present

Splenic injury
stable

Treatment for other Figure 777 Algorithm for non-

sources of blood loss operative management of blunt
splenic injuries.

Figure 778 Computed tomography (CT) scan depicts grade III

splenic injury. (Courtesy of Eduardo Bastos, General Surgeon, Marilia,
Brazil; reproduced with permission from www.trauma.org.)
 77 MANAGING INJURIES TO THE SPLEEN
CT scan may be performed with intravenous contrast.
On occasion, the initial CT scan may not reveal the true
grade of splenic injury or an injured vessel that was previ-
ously in spasm that may now have relaxed and started to
hemorrhage. Patients with such ndings may benet from
angioembolization. However, if the patient has required
2 or more units of blood or has undergone prior angio-
embolization, operative intervention is indicated. Other
causes for NOM failure include late bleeding (before or
after discharge), abscess formation, and splenic artery
pseudoaneurysm.
CONCLUSION
Careful selection, CT scanning, and serial clinical exami-
nations are crucial to the successful NOM of patients with
blunt splenic injuries. Angioembolization has enhanced
our ability to salvage a patients spleen without an opera-
tion. Patients requiring splenorrhaphy are best managed
with adequate exposure and mobilization. ABC, brin
glue, and absorbable mesh wrap appear to have advanced
the art of splenic salvage beyond the level achieved by
topical hemostatic agents, suturing, and partial splenec-
tomy. Finally, patients who are unstable or who do not
meet the selection criteria for splenic salvage should receive
a splenectomy with careful avoidance of the pitfalls
described in this chapter.
REFERENCES
1. Dunham CM, Cornwell EE, Militello P. The role of
argon beam coagulator in splenic salvage. Surg Gynecol
Obstet 1991;173:179.
2. Fingerhut A, Oberlin P, Cotte JL, et al. Splenic salvage
using an absorbable mesh: feasibility, reliability and safety.
Br J Surg 1992;79:325327.
3. Delany HM, Rudavsky AZ, Lan S. Preliminary clinical
experience with the use of absorbable mesh splenorrhaphy.
J Trauma 1985;25:909913.
4. Berry MF, Rosato EF, Williams NN. Dexon mesh splenor-
rhaphy for intraoperative splenic injuries. Am Surg 2003;
69:176180.
797
5. Bohicchio GV, Arciero C, Scalea TM. The hemostatic
wrap: a new technique in splenorrhaphy. J Trauma 2005;
59:10031006.
6. Styrt B. Infection associated with asplenia: risks, mecha-
nisms, and prevention. Am J Med 1990;88:33N.
7. Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury
scaling: spleen and liver (1994 revision). J Trauma 1995;
38:323324.
8. Duke BJ, Modin GW, Schecter WP, Horn JK. Transfu-
sion signicantly increases the risk of infection after splenic
injury. Arch Surg 1993;128:11251130; discussion 1131
1132.
9. EAST Practice Management Guidelines Work Group.
Practice Management Guidelines for the Non-Operative
Management of Blunt Injury to the Liver and Spleen.
Eastern Association for the Surgery of Trauma, 2003.
Available at http://www.east.org/tpg/livspleen.pdf
(accessed June 14, 2006).
10. Schurr MJ, Fabian TC, Gavant M, et al. Management of
blunt splenic trauma: computed tomographic contrast
blush predicts failure of non-operative management. J
Trauma 1995;39:507513.
11. Cooney R, Ku J, Cherry R, et al. Limitations of splenic
angio-embolization in treating blunt splenic injury.
J Trauma 2005;59:926932.
12. Haan HM, for the Western Trauma Association Multi-
Institutional Trials Committee. Splenic embolization
revisited: a multi-center review. J Trauma 2004;56:
542.
13. Fata P, Robinson L, Fakhry S. A survey of EAST member
practices in blunt splenic injury: a description of current
trends and opportunities for improvement. J Trauma
2005;59:836842.
14. Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury
in adults. Multi-institutional study of the Eastern Associa-
tion for the surgery of trauma. J Trauma 2000;49:177
189.
15. Feliciano D, for the AAST Spleen Study Group. Nonop-
erative management of the injured spleen: a prospective
study from the AAST Multi-institutional trial committee.
Presented at the American Association for the Surgery
of Trauma 2004, Annual Meeting. September 29 to
October 2, 2004, Grand Wailea Resort Hotel & Spa,
Maui, HA.
78
Damage Control:
Abdominal Closures
Benjamin Braslow, MD, Bruno Molino, MD,
and Vicente H. Gracias, MD
INTRODUCTION
Massive hemorrhage ranks second only to central nervous
system injuries as the leading cause of prehospital trauma-
related mortality.1 Moreover, uncontrolled bleeding stands
atop the list of early in-hospital mortality due to major
trauma.2 Regarding penetrating trauma patients, increas-
ing use of newer, more powerful automatic rearms, now
common in the civilian population, have resulted in more
frequent multiple penetrations (often multicavity) with
more severe degrees of tissue destruction and bleeding.3
This is even more pronounced in injuries sustained from
high-velocity military weaponry now being experienced all
too frequently in the global theater of war and terrorism.
Advances in prehospital care and trauma bay resuscitations
since the mid 1980s has resulted in a greater number of
these severely injured patients surviving to the point of
necessitating operative intervention. Such patients usually
present nearing physiologic exhaustion with profound aci-
dosis, hypothermia, and coagulopathy, the so-called lethal
triad of hemorrhage. The traditional surgical approach
to such patients, in which surgeons would denitively
repair all identied injuries at the initial operation, proved
inadequate with extremely high mortality despite control
of anatomic bleeding. During the peak of gun violence in
the late 1980s into the early 1990s, urban American
trauma centers gained extensive experience in treating
these patients and the concept of Damage Control
(DC) surgery was born. Borrowed from the Navy, the
term damage control referred to any and all methods
used to keep a badly damaged ship aoat to maintain
mission integrity.4 For the trauma surgeon, DC describes
the process of abbreviated laparotomy and expedient
control of hemorrhage and contamination followed by
intra-abdominal packing and temporary coverage. From
the operating room (OR), the patient is taken to the
surgical intensive care unit (SICU) for physiologic resus-
citation. Finally, the patient returns to the OR, after phys-
iologic capture, for denitive repair of all injuries and, if
possible, abdominal wall closure. To the uninformed
observer, the increased morbidity associated with this
multistep process might seem like surgical failure or aban-
donment of proper technique. Despite the associated high
morbidity, the DC sequence has proved to be an aggres-
sive and effective strategy to combat the lethal pattern
of physiologic failure associated with severe blunt and
penetrating injury.58
INDICATIONS
Because of the associated morbidity that accompanies the
DC process, patient selection and proper timing are
crucial. Although major liver injury and progressive coag-
ulopathy remain the most frequent indications, the list
continues to expand. In 1997, Rotundo and Zonies9
organized the key factors in patient selection for DC
into three categories: conditions, complexes, and critical
factors. In 1998, Moore and coworkers10 offered their six
major indications for abbreviated laparotomy with consid-
eration for institutional available resources and expertise.
Ultimately, the decision to proceed with DC principles
rests on the surgeon present and is based on the physiol-
ogy of the patient.
Inability to achieve hemostasis due to coagulopathy
Inaccessible major venous injury (pelvis, liver, etc.)
Time-consuming procedure in a patient with sub-
optimal response to resuscitaton
Management of extra-abdominal life-threatening injury
Reassessment of intra-abdominal contents
Inability to reapproximate abdominal fascia due to
visual or abdominal wall edema
THE DC SEQUENCE
DC 0
Once a patients injury pattern and physiology are assessed
as critical and DC principles are initiated, time becomes
critical.
 800 SECTION XII: TRAUMA SURGERY
Consequence
Failure to recognize a patient necessitating early appli-
cation of DC principles. Aoki and associates in 200111
reported on 68 patients who underwent DC surgery at
Ben Taub Hospital. Failure to correct pH above 7.21
by the conclusion of DC I and a PTT greater than 78.7
were predictive of 100% mortality. Likewise, in their
review of iliac vascular injuries in 1997, Cushman and
colleagues12 reported a fourfold greater risk of dying
for the hypothermic patient (preoperative core tem-
perature of 34C). This stresses the importance of
early implementation of DC principles to avoid reach-
ing this level of physiologic demise.
Grade 5 complication
Repair
Truncated scene times for emergency medical services
and rapid trauma bay throughput are essential to get
the patient to the OR, where hemorrhage control can
be best addressed.
Prevention
Important steps during this phase include obtaining
large-bore intravenous (IV) access, rapid-sequence
intubation for airway control, gastric decompression
(nasogastric tube placement is contraindicated in the
presence of facial trauma or basilar skull fractures),
chest tube placement (if indicated by absent breath
sounds or crepitus), early rewarming maneuvers, and
early blood product resuscitation. Large-volume crys-
talloid resuscitation increases the risk of subsequent
edema and dilutional coagulopathy.13 Minimal diag-
nostic x-rays are required. A chest x-ray after rapid-
sequence intubation is useful to conrm tube position
and identify immediately treatable hemo- and/or pneu-
mothorax. In the unstable blunt trauma patient, a
pelvic x-ray can identify signicant pelvic fractures that
must be temporarily stabilized to reduce pelvic volume
and help tamponade bleeding. Also, for suspected blunt
trauma, spinal precautions including a cervical collar
must be continued until denitive injury can be
excluded. A focused abdominal sonography in trauma
(FAST) examination can be helpful in rapidly conrm-
ing intraperitoneal bleeding when the physical exami-
nation is equivocal and multicavitary trauma is suspected.
This technique has supplanted diagnostic peritoneal
lavage in many institutions for this purpose. Commu-
nication with the blood bank is essential to keep them
abreast of the potential for massive transfusion require-
ments. Likewise, early communication with the anes-
thesia service is paramount to hasten their preparation
for this complicated patient and to initiate prewarming
of the OR. A Cell Saver device should be mobilized to
the OR for collection and reinfusion of shed autolo-
gous blood. Before incision, broad-spectrum antibiot-
ics and tetanus prophylaxis should be administered and
a Foley catheter placed.
DC I
The primary objectives of the initial laparotomy are control
of hemorrhage, limiting contamination (and the subse-
quent inammatory response), and temporary abdominal
wall closure to protect viscera and limit heat loss. All of
this ideally is accomplished in under 2 hours (about the
length of a music CD).
DC I STEPS
Step 1 Positioning and incision
Step 2 Manual abdominal wall retraction and four-
quadrant abdominal packing
Step 3 Division of falciform ligament
Step 4 Placement of large self-retaining retractor
Step 5 Sequential removal of packs; abdominal
inspection
Step 6 Exposure and control of vascular or solid organ
hemorrhage (pack, ligate, shunt, resect)
Step 7 Control of contamination from hollow viscus
injury (isolation, resection, repair)
Step 8 Repacking of abdomen
Step 9 Temporary abdominal closure
Step 10 Transport to SICU
Positioning and Incision
Failure to Gain Access to Injured Body Cavities
Consequence
Failure to adequately prepare and position the patient
can result in failure to gain access to injured body
cavities and limit the ability to diagnose and treat
hemorrhage.
Grade 5 complication
Repair
The patient is placed supine on the OR table with the
right upper extremity extended at a right angle from
the torso. The left arm is placed on an arm board
with the elbow partially exed and the arm extended
above the level of the head (a modied taxi-hailing
position). This leaves the left chest widely accessible for
emergent thoracotomy if necessary. The patient is pre-
pared from the chin to the knees anteriorly and down
to the level of the bed laterally. A vertical midline inci-
sion from the xyphoid process to the pubis is ideal. In
the setting of a suspected severe pelvic fracture, the
inferior limit of this incision can be curtailed to just
below the umbilicus. This will prevent loss of tampon-
ade of a retroperitoneal pelvic hematoma.
Prevention
In anticipation of the potential need for a median ster-
notomy, resuscitative left thoracotomy, or bilateral
tube thoracostomy, no leads or tubing should be
 78 DAMAGE CONTROL: ABDOMINAL CLOSURES
present on the anterior or lateral chest wall. Incision
should not be delayed while waiting for insertion of
invasive monitoring devices (arterial lines and central
venous catheters). A posterior heating pad is ideal
because a convection warm air blanket becomes
impractical.
If the patient has had a previous midline laparotomy, a
bilateral subcostal incision can be used. This allows for
rapid access to the peritoneal cavity away from the anti-
cipated midline adhesions. These adhesions can then be
lysed quickly under direct vision.
Division of the Falciform Ligament and
Placement of a Large, Self-retaining Retractor
Iatrogenic Injury to the Abdominal Contents
Consequence
Once in the abdomen, a large hand-held abdominal
wall retractor is used circumferentially to create space
for extensive packing of all four quadrants. Iatrogenic
injury to the abdominal contents can occur during this
rapid, forceful maneuver. Often, bowel loops are com-
pressed between the retractor and the abdominal wall
and are bruised or torn or traction injury to the liver
occurs.
Grade 2 complication
Prevention
The hand-held body wall retractor must be initially
placed under direct vision as the surgeon or assistant
widely pushes down on the abdominal contents to
create an area of separation between the abdominal
contents and the abdominal wall. The retractor is then
slid along the abdominal wall, maintaining the zone of
separation. Packs (laparotomy pads) are carefully placed
into the gutters and pelvis as the bowels are swept in
the opposite direction. Surgeons on opposite sides of
the table trade retracting and packing duties as appro-
priate. The falciform ligament is rapidly divided all the
way to the dome of the liver to prevent iatrogenic trac-
tion injury to the liver during suprahepatic pack place-
ment. Next, a large self-retaining retractor is placed to
liberate all surgical hands available and maximize expo-
sure. Next, packs are removed in a sequential fashion,
beginning in the areas least likely to harbor the source
of major hemorrhage. This provides space to pack the
bowels away from areas of bleeding and create maximal
exposure.
Hypotension
Consequence
Once the peritoneum is opened, any tamponade effect
that had been provided by the abdominal wall is imme-
diately lost. This may induce abrupt and severe hypo-
tension. Sometimes, the patient remains profoundly
hypotensive after four-quadrant packing is complete.
Grade 5 complication
801
Repair
Control of aortic inow should be obtained. Manual
occlusion of the aorta at the diaphragmatic hiatus can
be performed quickly by passing ones hand anterior to
the stomach underneath the left hepatic lobe. The aorta
can be palpated immediately to the right and posterior
to the esophagus. Here, it can be compressed posteri-
orly against the vertebral body either manually or with
an aortic occlusion device. This maneuver has been
shown to not only slow intra-abdominal bleeding but
also augment cerebral and myocardial perfusion while
anesthesia catches up on volume replacement and the
source of bleeding is identied and controlled.14 If,
for some reason, control of aortic inow cannot be
controlled from within the abdomen, an emergent left
thoracotomy can be performed and the descending
aorta cross-clamped from within the thorax. This adds
morbidity to the procedure but, for some surgeons,
allows for more rapid control of the aorta.
Sequential Removal of Packs;
Abdominal Inspection
Retroperitoneal Hematoma
Consequence
A centrally located retroperitoneal hematoma is
encountered. Injury to a major vascular structure is
anticipated.
Grade 5 complication
Repair
As is true in all vascular surgery, exposure is the key
rst step. The small bowel is initially eviscerated. This
is followed by left and/or right medial visceral rotation
to expose centrally located vessels. Often, packing alone
is adequate for some vascular injuries, specically
venous. If an injury is amenable to rapid arteriorrhaphy
or venorrhaphy, this is the treatment of choice. Of
note, almost every vessel in the abdomen can be ligated
with limited morbidity.15 However, ligation of the main
aorta, external iliac arteries, and proximal superior mes-
enteric artery are associated with devastating tissue
and/or bowel ischemia potentially necessitating limb
amputation or extensive small bowel resection. Tem-
porary intraluminal shunts are relatively easy to place
and maintain end-organ perfusion. They are secured in
place using silk ties or Rumel tourniquets. The largest
shunt that ts easily within the vessel should be used.
Argyle carotid shunts and Javid shunts work well on
medium-sized vessels, whereas chest tubes may be used
when larger conduits are required (aorta or inferior
vena cava). Literature on DC shunting of abdominal
vessels is sparse and mostly limited to case reports;
nevertheless results are encouraging.16,17 The feasibility
of major abdominal and pelvic vein shunting in criti-
cally injured patients is controversial because published
 802 SECTION XII: TRAUMA SURGERY
patency rates are low. However, it has been proposed
that temporary shunting may help control short-term
edema during acute high-volume resuscitation. In the
context of DC surgery, there is no justication for
wasting time with pelvic vein shunting or reconstruc-
tion.18 When ligation is performed, the clinically sig-
nicant edema rate does not appear to be different from
that of repaired veins if leg elevation, compression
stockings, and liberal use of fasciotomies are utilized.19
Tense laparotomy pad packing and/or inatable
balloon catheters (e.g., Foley or Fogarty catheters) can
be utilized for persistent hemorrhage from inaccessible
locations or uncontrollable vessels. They may be placed
directly into the missile or knife tract or directly into
the defect in the injured vessel.
Solid Organ Injury
Consequence
Ongoing bleeding from solid organ injury.
Grade 4 complication
Repair
With respect to solid organ injuries, prolonged repair
for bleeding must be avoided. Splenic and renal hemor-
rhage is best managed with prompt resection, especially
when the patient is approaching physiologic exhaus-
tion. Tight packing anteriorly and posteriorly initially
controls bleeding from liver parenchyma. Ongoing
deep parenchymal bleeding is then controlled by com-
pression of the porta hepatis (Pringles maneuver),
followed by a nger fracture technique to expose deep
vessels for suture ligation or clip application.20 More
complex injuries (e.g., transhepatic gunshot wounds
with long narrow columns of injury and active bleed-
ing) require more innovative techniques like the inser-
tion of a Penrose drain ligated distally, secured to and
inated over a red rubber catheter.21
Any and all topical hemostatic agents can be applied as
well including brin glue. A liver tampon made up of
several sausage-sized pieces of absorbable gelatin sponge
(Gelfoam) soaked in thrombin solution and wrapped
loosely in a sheet of oxidized cellulose (Surgicel) is a
recommended hemostatic modality. This device is then
stuffed into the parenchymal defect followed by addi-
tional packing. This effectively tamponades bleeding
and creates a hemostatic milieu.22 Tampons composed of
other absorbable hemostatic materials available to the
surgeon are also feasible.
Prevention
After the completion of DC I, all cases of complex
hepatic injury should be interrogated with angiogra-
phy. Even in those cases in which hemostasis is seem-
ingly achieved, there can be a high incidence of ongoing
intrahepatic arterial bleeding or traumatic arteriove-
nous stula, which requires therapeutic embolization.
Control of Contamination from a Hollow Viscus
Injury (Isolation, Resection, Repair)
Ongoing Intra-abdominal Contamination
Consequence
Ongoing intra-abdominal contamination from a hollow
viscus injury.
Grade 3 complication
Repair
After cessation of hemorrhage, limiting contamination
becomes the next highest priority. This is done by
controlling spillage of intestinal contents and urine
from hollow viscus injuries. Simple bowel injuries,
limited in size and number, are initially controlled with
Babcock clamps and repaired using simple, single-layer
continuous suture and tagged for reinspection later.
More extensive injured bowel segments can either be
isolated with proximal and distal circumferential umbil-
ical tape or be divided with gastrointestinal anastomo-
sis stapling devices. Formal resection can be postponed,
and denitive reconstruction or ostomy creation is
avoided at this time. This concept is very important
when dealing with high-velocity penetrating wounds
because the extent of bowel wall edema and blast injury
is often underappreciated at the initial operation. This
can cause delayed bowel ischemia and threaten anasta-
moses and stomas.
Options for the management of ureteral injuries during
DC include ligation and exteriorization. Ligation will
require temporary percutaneous or open nephrostomy
after several days if denitive repair is delayed for a pro-
longed period of time. Temporary percutaneous ureter-
ostomy avoids this complication. Here, a tube is inserted
into the proximal ureter and brought out laterally through
the skin. Most bladder injuries can be rapidly closed with
a single-layer running suture for initial management.23
Biliary tract and pancreatic injuries can be temporarily
controlled by intra- or extraluminal tube drainage to tem-
porarily diminish the damaging effects of pancreatic
enzymes and bile on surrounding tissues. Again, all drains
must be placed laterally so as not to interfere with tem-
porary abdominal wall closure options.
Prevention
Meticulous inspection of the entire intra-abdominal
and retroperitoneal digestive and urinary tract is para-
mount. The extent of intervention is based upon patient
physiology.
Repacking of the Abdomen
Ongoing Bleeding
Consequence
Ongoing bleeding from raw surface areas created
during extensive retroperitoneal or pelvic dissection. In
 78 DAMAGE CONTROL: ABDOMINAL CLOSURES
the coagulopathic patient, these areas can be respon-
sible for massive blood loss.
Grade 3 complication
Repair
Correction of coagulopathy and adequate repacking at
the conclusion of DC I. Once all vascular and bowel
injuries have been controlled, diffuse intra-abdominal
packing is performed. This technique is especially
important when coagulopathy is noticed and exten-
sive retroperitoneal or pelvic dissection has been per-
formed.24,25 Folded laparotomy pads are rst placed
over any solid organ injuries as well as over all dissected
areas.
Prevention
Packing should be tight enough to provide adequate
tamponade without compromising venous return to
the heart or distal arterial supply.26
Temporary Abdominal Closure
Increased Risk of Abdominal
Compartment Syndrome
Consequence
Formal closure of the abdominal fascia after DC
laparotomy has been associated with increased risk of
abdominal compartment syndrome (ACS), acute respi-
ratory distress syndrome, and multisystem organ failure.
These conditions result from postoperative reperfusion
injury and ongoing capillary leakage during DC II,
causing intestinal and abdominal wall edema.
Grade 4 complication
Prevention
Temporary abdominal closure is the nal step in
the initial laparotomy prior to transport to the SICU.
The goals of temporary closure include containment
of abdominal viscera, thermoprotection, control of
abdominal secretions, and maintenance of intra-
abdominal pressure tamponade.
The simplest option for temporary closure includes
skin-only closure using towel clips or a running nonab-
sorbable suture. This allows for considerable abdominal
domain expansion while maintaining an insulating, pro-
tective shield. Note that towel clips, although the quickest
method to deploy, can interfere with postoperative
imaging studies (e.g., arteriography). If bowel edema pre-
vents skin approximation, a temporary silo device is an
option. The Bogot bag is a 3 L IV uid bag sewn to the
skin along the perimeter of the incision. This rapid, cheap
closure technique, however, allows the abdominal fascia
to retract considerably, potentially complicating denitive
closure later. The vacuum dressing has evolved as the
alternative of choice. This device can be placed quickly
and allows for considerable increase in abdominal volume
while maintaining some inward traction on the fascia.
803
Controlled egress of uid from the abdomen is permitted
while maintaining a sterile, secure barrier, suitable for
prone positioning ventilation if necessary. This dressing is
composed of a surgical towel wrapped in Ioban and tucked
subfascially over the bowel and omentum, which, if
present, should be used to drape the small bowel and
should be spread caudally and laterally to act as an abdom-
inal apron. Two closed suction drains are then placed atop
this dressing and are kept to high wall suction. Several
laparotomy pads are placed over these drains, followed by
a nal external Ioban sheet over the entire abdomen. To
ensure that the Ioban sticks securely to the skin, all
abdominal wall hair, especially in the groin and the supra-
pubic areas, is shaved and the skin is painted with a thin
layer of benzoin. The dressing collapses down under
suction and becomes semirm if placed properly.
Failure to Control Surgical Bleeding
Consequence
Failure to control surgical bleeding from a source in
an anatomic location not amenable to denitive rapid
surgical control. This is particularly true for complex
hepatic, retroperitoneal, and pelvic or deep muscle
injuries that would require lengthy surgical exploration
often in the setting of coagulopathy.
Grade 4 complication
Repair
DC I is not complete until all surgical bleeding is con-
trolled. Although venous bleeding from these sources
is often controlled with packing alone, an arterial bleed-
ing source will often require an interventional radiology
(IR) procedure to achieve or prolong hemodynamic
stability.27
Prevention
The IR team should be contacted and mobilized early
in DC I if it is suspected that they will be needed. It is
imperative that DC II strategies be initiated and main-
tained while the patient is in IR. SICU personnel and
resources might need to be mobilized to the IR suite
for this purpose.
DC II
The goal of DC II is to reverse the sequelae of shock,
specically the lethal triad of hypothermia,28,29 acidosis,30
and coagulopathy, and support physiologic and biochem-
ical restoration. Accordingly, any and all measures avail-
able for core rewarming should be utilized including
raising the ambient temperature of the room and warming
IV uids and the ventilator circuit. A convection hot air
blanket is reapplied anteriorly, and if available, a uid
circulating heating pad is placed posteriorly on the back
and thighs. Other, more aggressive measures include
pleural, gastric, and bladder lavage with warmed uids.
Occasionally, extracorporeal circulation devices like
venovenous or arteriovenous bypass via femoral vessel
 804 SECTION XII: TRAUMA SURGERY
cannulation are necessary for rapid correction of severe
hypothermia (core temperature 28C32C). Use of
venovenous bypass is limited by its requirement for sys-
temic anticoagulation.31
Coagulopathy, a direct result of both hypothermia
and resuscitative dilution of clotting factors, is treated by
aggressive administration of fresh frozen plasma, platelets,
and cryoprecipitate if brinogen levels fall. Recombinant
activated factor VII is a relatively new product available to
combat clinical coagulopathy that does not correct with
standard measures.32,33
The metabolic acidosis that results from hypovolemic
shock and tissue ischemia causes an uncoupling of -
adrenergic receptors. This diminishes the bodys response
to endogenous and exogenous catecholamines and mani-
fests primarily in lowered cardiac output and hypotension.
This is treated by a predominant biologically active colloid
(packed red blood cells, fresh frozen plasma, platelet)
resuscitation to optimize oxygen delivery, cardiac output,
and coagulation parameters. This resuscitation should
be guided by at least central venous and invasive arterial
pressure monitoring. In elderly patients with other
comorbidities, a pulmonary artery catheter may be neces-
sary. Crystalloid administration should be limited
(<10 L) to control bowel edema and pulmonary third
spacing.34
Injuries Sustained during Trauma
Consequence
Other injuries sustained during trauma remain unde-
tected during DC sequence.
Grade 3 complication
Repair
Injury specic by appropriate consulting service.
Prevention
During DC II, a complete physical examination or
tertiary survey of the patient should occur. Appropri-
ate radiographs should be obtained to evaluate for
additional skeletal injuries based on physical ndings
that induce suspicion such as gross deformity or bruis-
ing. Immobilization and/or traction devices are applied
when indicated. In the case of associated blunt mecha-
nism, completion of the spine survey is imperative.
Peripheral wounds are addressed, and vascular integrity
of all injured limbs is frequently assessed. Adjunctive
studies such as computed tomography scanning should
be obtained at this time unless the patient is too unsta-
ble for travel. Recruitment of consultants for all den-
itive repairs should occur early in this phase, and
both the extent and the priority of repairs must be
established.
Two subgroups of patients emerge who require prema-
ture reoperation during DC II prior to achieving physi-
ologic restoration.
High Packed Cell Transfusion Requirement
Consequence
Patient maintains a high packed cell transfusion require-
ment despite normalization of temperature and coagu-
lation factors. This is due to continued surgical
bleeding either not identied at the conclusion of DC
I or new-onset hemorrhage secondary to clot disrup-
tion or vasodilation.
Grade 3 complication
Repair
Once recognized, immediate operative reexploration or
IR reinterrogation to localize and stop the bleeding
must occur.
Prevention
Throughout DC II, the patient should remain sedated
on complete ventilation support. Chemical paralysis
is used to promote synchrony with the ventilator and
prevent disruption of clot formed in the packed open
abdomen. Also, care must be taken to ensure that
the patient does not become signicantly hyperten-
sive during the DC II resuscitative phase because
this can have deleterious effects on clot stability and
hemostasis.
Development of ACS
Consequence
Patient develops ACS, usually from bowel edema. ACS
is dened as an intra-abdominal pressure (bladder
pressure measured via a Foley catheter) of greater than
25 mm Hg associated with one or all of the following
physiologic sequelae: elevated peak airway pressures,
impaired ventilation associated with hypoxia and
hypercarbia, decreased urine output, increased systemic
vascular resistance, and decreased cardiac output.35 This
occurs in approximately 6% of patients after DC lapa-
rotomy for severe abdominal and/or pelvic injuries.36
These patients are at high risk for the development of
intra-abdominal hypertension (IAH) from several
causes: the use of bulky abdominal packs, continued
bleeding into the abdominal cavity from uncorrected
coagulopathy or failed and/or unrecognized mesen-
teric vascular injuries, bowel distention and edema
from extensive resuscitation volumes (>10 L), and
abdominal wall edema. A vacuum pack closure does not
eliminate the possibility of ACS.37 This may be due to
the efciency with which the vacuum pack dressing is
able to contain the abdominal volume and allow sub-
sequent rises in abdominal pressures as visceral and
abdominal wall edema worsens.
Grade 4 complication
Repair
Treatment consists of immediately opening the patients
abdomen to relieve the pressure. If ongoing blood loss
 78 DAMAGE CONTROL: ABDOMINAL CLOSURES
is suspected as the cause of the increased intra-abdom-
inal pressure, this is best performed in the OR where
lighting and equipment availability are maximized, if
the patient can tolerate the necessary transport. The
emergency alternative is to open the abdomen at the
bedside in the intensive care unit (ICU) under sterile
conditions. Occasionally, adequate decompression can
be achieved without extensive operative intervention by
incising the external Ioban drape of the vacuum pack
to allow for further expansion of the neoabdominal wall
and more eventration of abdominal viscera prior to
placement of a new sterile Ioban cover. Failure to treat
immediately is associated with extreme mortality.
DC III
The primary objectives of DC III are denitive organ
repair and fascial closure, if possible. Physiologic capture
usually takes 24 to 36 hours to achieve, even with aggres-
sive ICU management. In the OR, all packs are copiously
irrigated and carefully teased off raw surfaces to avoid clot
disruption. If diffuse bleeding is encountered, the surgeon
must be prepared to abort the procedure, repack, and
return after further resuscitation.
After successful pack removal, the abdomen is reex-
plored to assess repairs made during DC I and to identify
missed injuries. Formal vascular repairs are performed, and
intestinal continuity is restored. Any bowel anastamoses
should be covered with omentum and/or tucked under
mesentery to promote sealing without stula formation.
Stoma creation and percutaneous feeding tubes are avoided
if fascial closure does not seem possible. Ideally, a naso-
gastric decompression tube and nasojejeunal feeding tube
should be positioned intraoperatively. If a stoma is neces-
sary (and fascial closure is to be delayed), it should be
placed as laterally as possible to allow subsequent mobili-
zation and separation of the abdominal wall components
when denitive closure is performed.
Retained Foreign Body after Closure
Once all of the repairs are completed, formal abdominal
of the Abdomen
closure without tension is the nal step in the planned
reoperation sequence.
Denitive Closure Techniques
Primary Closure
This is the most preferable closure. Maneuvers to tempo-
rarily approximate the fascial edges should be performed
with clamps. If gentle abduction allows the fascial edges
to approximate, a standard fascial closure should be pos-
sible. The risk of infection, enterocutaneous stula (ECF),
and recurrent wound problems appears to be lower. This
may be delayed days to weeks as physiology improves and
edema lessens.
Persistent Edema
Consequence
Persistent edema within the retroperitoneum, bowel
wall, and abdominal wall often renders primary fascial
805
closure impossible at the time of the original take-back
operation after DC I and II. Attempting to close too
large a defect can lead to ACS and its associated phys-
iologic sequelae.
Grade 3 complication
Repair
Patients who develop ACS will require reoperation to
release and reopen the abdomen.
Prevention
A determination will need to be made at the time of
closure as to the tension that will be placed on the
abdomen and whether it can be close primarily or not.
The surgeons judgment is most important here. In
general, if, when the abdomen is viewed from across
the OR table, the bowels are visualized above the level
of the skin, then a low-tension primary closure is
unlikely. Generally, a gap larger than 4 cm between
fascial edges cannot be successfully closed primarily.38
Another good rule to follow is that if the peak airway
pressure rises more than 10 cm H2O during temporary
fascial approximation, the fascia should be left open and
the aforementioned vacuum pack closure replaced. The
patient is then returned to the ICU, and aggressive
diuresis is implemented over the next several days if
hemodynamically tolerated. This helps to decrease
bowel and body wall edema. During this period, the
patient undergoes a daily abdominal washout, reinspec-
tion, and meticulous replacement of the vacuum pack
dressing so as not to promote stula formation. This
can occur at the bedside if personnel and resources are
readily available. The majority of damage controlled
open abdomens can be primarily closed within 7 to 10
days, especially if there is no sign of intra-abdominal
infection.
Consequence
All sponges and instruments are not removed prior to
closure. The emergent nature of the trauma of DC
laparotomy increases the likelihood of retained foreign
body.39 Multiple sponges used for packing as well as
certain instruments are initially intentionally left in the
abdomen. These may be unrecognized and left behind
after denitive closure.
Grade 3 complication
Repair
Retained foreign body will require reexploration and
removal.
Prevention
Do not rely on sponge counts at the time of denitive
closure. Obtain an intraoperative abdominal radiograph
to ensure that no retained foreign bodies are present
 806 SECTION XII: TRAUMA SURGERY
prior to proceeding with closure. Be sure that the
radiograph displays the entire abdominal cavity. For
obese patients, multiple radiographs might be necessary
to properly view all four abdominal quadrants.
Approximately 20% of DC patients fail primary fascial
closure and are managed as open abdominal wounds or
large ventral hernias. If fascial closure is still not achieved
after 7 to 10 days, the surgeon faces a number of alterna-
tives that will cover the abdominal defect but leave the
patient with a large ventral hernia. The rst of these involves
closing the skin with no attempt at fascial reapproxima-
tion. The patient would then undergo repair of the
abdominal wall defect several months later. Often, this is
not possible because the gap is too wide and, despite skin
ap mobilization, the edges cannot be approximated.
In a second option, a Vicryl (polyglycolic acid) mesh is
placed over the entire abdominal wall defect and sutured
to the fascial edges. The Vicryl mesh is then covered with
saline-soaked wet-to-dry dressings. It is always advisable
to drape the greater omentum, if still available, over the
bowel so that frequent dressing changes do not promote
formation of enteric stulas. Careful daily dressing changes
are performed over this mesh, and the wound is allowed
to granulate through the material. Once a smooth bed of
granulation tissue is established (23 wk), a sponge
vacuum dressing can then be applied to promote faster
granulation.
Enteroatmospheric Fistula
Consequence
Exposed suture lines, anastomoses, or bowel wall
exposed to the mesh or fascial edges may result in
enteroatmospheric stulae. Frequent manipulation
(i.e., dressing or vacuum pack changes) of the granulat-
ing wound compounds this risk. These can be even
more challenging to manage than ECF owing to the
lack of skin to apply an appliance to control drainage.
Grade 4 complication
Repair
The same principles apply here as to ECF, with the
addition of the necessity to provide skin coverage
around the stula site. It is most important not to
attempt a split-thickness skin graft (STSG) until the
stula drainage is controlled so as to not jeopardize the
chance for a successful take. It may be necessary to
stage the STSG. By allowing the stula output to drain
opposite the side of grafting, half of the wound area
can be covered before proceeding with grafting the
remainder of the wound and allowing the output to
drain out the grafted side. This can be accomplished
by temporarily positioning the patient in ways that
allow gravity to determine the direction of drainage.
Prevention
The same principles apply here as to ECF.
Next, an STSG is applied once the granulation bed
matures. Over the next 6 to 12 months, this skin graft will
mature, separate, and develop a thin layer of connective
tissue or fat between the underlying viscera. At this point,
the patient is ready for excision of the skin graft and
denitive reconstruction. Many reconstructive techniques
have been described in the literature, including the use
of preoperative tissue expanders40 and abdominal wall
component separation with bilateral rectus release to
achieve primary component closure with extrafascial mesh
support.41 Here, the external oblique aponeurosis is incised
approximately 2 cm lateral to the rectus sheath and sepa-
rated from the internal oblique. This allows the rectus
muscle to be approximated medially and sutured. Various
modications of this technique have been described.42 The
involvement of a plastic surgeon at this step is advisable
to lend additional expertise at this delayed setting.
Dense Abdominal Adhesions
Consequence
Dense abdominal adhesions will make the dissection of
the skin graft off of the intestines very difcult. This
may lead to prolonged operative times and incur many
enterotomies, thus contaminating the operative eld.
Grade 3 complication
Repair
Standard enterotomy closures or bowel resection.
Prevention
Wait at least 6 months to a year before scheduling a
patient for reconstruction. All acute processes of the
original pathology must be resolved, nutritional status
must be satisfactory, and the abdomen must pass the
pinch test (the skin graft is pinched and is able to be
elevated off of the abdominal contents without palpa-
ble adhesions).
ALTERNATIVES TO
COMPLEX ABDOMINAL
WALL RECONSTRUCTIONS
Permanent Prosthesis
Nonabsorbable mesh is often used to bridge the gap
between fascial edges. Unfortunately, this is associated
with high recurrence and stula rates.43,44 The main advan-
tage of permanent mesh closure is avoidance of complex
abdominal wall reconstruction. Options for permanent
prosthesis include polypropylene, expanded polytetrauo-
roethylene (ePTFE), composite material, and biologic
material. Polypropylene mesh incorporates well (usually
within 2 wk) secondary to broblastic reaction but can
have problems with shrinkage, adhesion formation, seroma
and infection (5%), and late recurrence. The ECF rate
is approximately 3%. ePTFE has less broblastic reaction
and adhesions than polypropylene and, thus, an increased
recurrence rate. Although ePTFE can be placed adjacent
to bowel, ECF remains a problem. This material is
also more expensive than polypropylene. A composite
 78 DAMAGE CONTROL: ABDOMINAL CLOSURES
material is available made up as a sandwich of ePTFE
placed down on the bowel and polypropylene facing up.
This allows an intraperitoneal placement and combines
the advantages of both materials while minimizing
complications.
ECF
Consequence
ECF appears to be a particularly challenging complica-
tion to manage and is due to bowel dessication and
adherence of bowel to the mesh and exposed fascial
edges. The bowel stulizes with the anterior abdominal
wall and its contents drain through the skin.
Grade 4 complication
Repair
ECF remains the Achilles heel of the general surgeon.
The management here is no different than traditional
teaching. The anatomy of the stula needs to be deter-
mined and output should be classied as high or low.
Nothing-by-mouth status and total parenteral nutrition
are instituted. If the stula fails to close spontaneously,
operation is required.
Prevention
Every attempt should be made to protect the bowel
from adhering to permanent mesh and fascial edges.
Suture lines and anastomoses are particularly vulnerable
to stulization. These should be buried if possible, so
as to minimize exposure to the rough surface. The
omentum can be used and is quite helpful in serving as
a barrier between the bowel and the anterior abdominal
wall. Nutrition should be optimized.
Biologic Material
Derived from the extracellular matrix from animal or
human tissue or cadaveric fascia, these materials have
a decreased incidence of infection and ECF. Their use
is preferred in contaminated wounds. Surgisis (Cook) is
derived from porcine small intestinal submucosa. It is
composed mostly of type I collagen from the extracellular
matrix and is acellular. It has been used successfully in
contaminated wounds.45,46 Alloderm (Lifecell) is human
acellular dermis from processed cadaveric skin. It consists
of the basement membrane and a dermal collagen matrix.
There is no antigenic response, and Alloderm has been
shown to be effective in abdominal wall reconstruction in
patients at increased risk for mesh-related complications.47
One drawback is its signicant expense ($25/cm2). Per-
macol, a porcine dermal collagen, is another biologic
material that has been on the market since 2001.
Recurrent Herniation
Consequence
As with all hernias, recurrences will occur at variable
times after repair.
Grade 3 complication
807
Repair
Reoperation is required. This may be accomplished by
the open or the laparoscopic method.
Prevention
A pitfall here is not overlapping enough mesh over the
defect edges. Laparoscopic experience indicates that at
least a 4-cm overlap should be used to avoid failure.
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79
Management of Penetrating
Neck Injury
Ali Salim, MD and Demetrios Demetriades, MD
INTRODUCTION
Penetrating neck injuries (PNIs) are notoriously difcult
to evaluate and manage because of the complex anatomy
and the dense concentration of numerous vital structures
in a small anatomic area. The clinical evaluation can be
challenging, and signicant injuries may easily be missed.
The radiologic evaluation of these injuries has undergone
major changes since the early 2000s and shifted from
invasive diagnostic procedures to noninvasive methods.
The selection of the most appropriate investigation remains
a controversial issue. The surgical exposure of some neck
structures such as the distal carotid artery, the subclavian
vessels, and the vertebral artery can challenge the surgical
skills of even the most experienced trauma or vascular
surgeons and require excellent knowledge of the local
anatomy. The advancement of interventional radiology
has revolutionized many aspects of the management of
some complex vascular injuries that are difcult to manage
operatively.
EPIDEMIOLOGY
Firearms are responsible for about 43%, stab wounds for
about 40%, shotguns for about 4%, and other weapons
for about 12% of all PNIs in urban trauma centers in the
United States.1 Gunshot wounds (GSWs) are signicantly
more likely to be associated with large neck hematomas,
hypotension on admission, and vascular or aerodigestive
injuries than are knife wounds.1,2 Overall, about 35% of
all GSWs and 20% of stab wounds to the neck are associ-
ated with signicant injuries to vital structures, but only
16.5% of GSWs and 10.1% of stab wounds require a
therapeutic operation. Transcervical GSWs are associated
with signicant injuries to vital structures in 73% of victims,
although only 21% require a therapeutic operation.3
Shotgun injuries account for about 4% of civilian PNIs,
often cause injuries to multiple structures, and pose major
evaluation and management problems. Overall, the most
commonly injured structures in the neck are the vessels,
followed by the spinal cord, the aerodigestive tracts, and
nerves.1 The incidence of injury to the various neck
structures according to mechanism of injury is shown in
Table 791.
ANATOMY
In penetrating trauma, the neck is divided into three
anatomic zones for evaluation and therapeutic strategy
purposes (Fig. 791): Zone I comprises the area between
the clavicle and the cricoid cartilage. This zone includes
the innominate vessels, the origin of the common carotid
artery, the subclavian vessels and the vertebral artery, the
brachial plexus, the trachea, the esophagus, the apex of
the lung, and the thoracic duct. The surgical exposure
of the vascular structures in Zone I is difcult because of
the presence of the clavicle. Zone II comprises the area
between the cricoid cartilage and the angle of the man-
dible and contains the carotid and vertebral arteries, the
internal jugular vein, the trachea, and the esophagus. This
zone is more accessible to clinical examination and surgi-
cal exploration than the other zones. Zone III extends
between the angle of the mandible and the base of the
skull and includes the distal carotid and vertebral arteries
and the pharynx. Zone III is not amenable to easy physi-
cal examination or surgical exploration.
MANAGEMENT
The initial evaluation and management should follow the
Advanced Trauma Life Support (ATLS) protocols. During
the primary survey, the following life-threatening condi-
tions from the neck should be identied and treated as
soon as possible:
1. Airway obstruction due to laryngotracheal trauma or
external compression by a large hematoma.
2. Tension pneumothorax.
3. Major active bleeding, externally or in the thoracic
cavity.
 810 SECTION XII: TRAUMA SURGERY

Zone III Zone III

Zone II Zone II

Zone I
Zone I

Figure 791 Surgical zones of the neck: zone I is between the clavicle and the cricoid; zone II is between the cricoid and the angle of
the mandible; and zone III is between the angle of the mandible and the base of the skull.

Table 791 Incidence and Type of Injuries according to

Mechanism of Injury (N = 223 Patients)1
Injury All Mechanisms GSW SW
(%) (%) (%)

Vascular 21.5 26.8 14.6

Aerodigestive 6.3 7.2 3.4

Spinal cord 6.7 13.4 1.1

Peripheral or cranial 9.0 12.4 4.5

nerves or sympathetic

Hemo- or pneumothorax 17.9 15.5 13.5

GSW, gunshot wounds; SW, stab wounds.

From Demetriades D, Theodorou D, Cornwell EE, et al. Evaluation of
penetrating injuries of the neck: prospective study of 223 patients.
World J Surg 1997;21:4148.
Figure 792 Patient with a large hematoma in zone I of the neck,
secondary to subclavian artery injury.

4. Spinal cord injury or ischemic brain damage due to ca-

rotid artery occlusion.
cheal intubation difcult and dangerous, even in an
During the secondary survey the following neck injuries ideal environment. Inability to secure the airway in
should be identied: such a patient can lead to severe respiratory distress
and, ultimately, cardiac arrest.
1. Occult vascular injuries.
Grade 4/5 complication
2. Occult laryngotracheal injuries.
Repair
3. Pharyngoesophageal injuries.
Cricothyroidotomy in the emergency room may be
4. Cranial or peripheral nerve injuries. necessary in about 6% of all PNIs4 or about 12% of
laryngotracheal injuries.5 In the presence of large
5. Small pneumothoraces.
midline hematomas, the procedure is difcult and may
The more common pitfalls initially encountered when be associated with severe bleeding.
dealing with patients with PNI follow. On rare occasions with visible large laryngotracheal
wounds, the endotracheal tube can be inserted under
direct view into the distal transected segment through the
Failure to Secure the Airway
neck wound. The distal larynx or trachea should be grasped
Consequence and secured with a tissue forceps before insertion of the
The presence of a large hematoma (Fig. 792) or tube in order to avoid complete transection or retraction
edema or laryngotracheal trauma makes the endotra- into the mediastinum.
 79 MANAGEMENT OF PENETRATING NECK INJURY
Prevention
Early recognition of the need for surgical airway is key.
Air bubbling through a neck wound is pathognomonic
of laryngotracheal injury. Firm manual compression
over the wound reduces the air leak and usually improves
oxygenation. Emergency room endotracheal intuba-
tion should be considered only in patients who fail to
improve after rm occlusion of the wound with the air
leak. Orotracheal intubation in the emergency room
should be performed by the most experienced physician
present, with a surgeon ready to perform a surgical
airway.
Active Hemorrhage
More than 20% of patients who sustain a PNI have
evidence of vascular injury (see Table 791). Patients
may present with a moderate to large hematoma or active
bleeding, either externally or into the thoracic cavity.
Consequence
Major active bleeding, externally or into the thoracic
cavity, is potentially life threatening and needs to be
addressed immediately after the airway has been secured.
In addition, venous injuries may lead to air embolism.
Without prompt attention, patients will suffer cardio-
vascular collapse.
Grade 3/4 complication
Repair
On arrival at the hospital, patients with active bleeding
should be placed in the Trendelenberg position to
reduce the risk of air embolism in cases with venous
injuries. In cases of suspected subclavian venous
injuries, the intravenous line should be inserted in the
opposite arm in order to avoid extravasation of infused
uids or medications from a proximal venous injury.
External bleeding can successfully be controlled by
direct pressure in most cases. However, bleeding from
the vessels behind the clavicle or near the base of the
skull or the vertebral artery is often difcult to control
by external pressure. In these cases, digital compression
with a gloved index nger through the wound should
be attempted. For these situations, we have successfully
used balloon tamponade.68 The technique involves
insertion of a Foley catheter into the wound and
advancement as far as it can go. The balloon is then
inated with water until the bleeding stops or moderate
resistance is felt. If the bleeding continues after this
maneuver, the balloon is deated and the catheter is
slightly withdrawn and reinated. Signicant bleeding
through the catheter is suggestive of bleeding distal to
the balloon and repositioning should be attempted. In
periclavicular injuries, the bleeding may occur in both
the intrathoracic cavity and externally. In these cases, a
Foley catheter is advanced into the chest cavity through
the neck wound, the balloon is then inated, and the
catheter is pulled back until some resistance is felt.
811
Balloon
compressing
bleeder
Figure 793 Balloon tamponade for bleeding control from the
subclavian vessels. It can also be used for bleeding control from
other zones in the neck.
In this position, the balloon compresses the bleeding
vessels against the rst rib or the clavicle (Fig. 793).
The traction is maintained by application of a Kelly
forceps on the catheter, just above the skin. If external
bleeding continues, a second Foley is inserted and
inated in the wound tract.7 Blind clamping of sus-
pected bleeding should be avoided because it is rarely
effective and the risk of further vascular or nerve
damage is very high.
Many patients with major injuries to the neck vessels
reach the hospital in cardiac arrest or imminent cardiac
arrest. These patients may benet from a resuscitative
thoracotomy. Bleeding from the left subclavian vessels can
be controlled with a vascular clamp applied under direct
view through the thoracotomy. Besides the usual resusci-
tation measures, the right ventricle should be aspirated
for air embolism. In our experience, survival after resusci-
tative thoracotomy for PNI is very poor.9
Prevention
The sequelae of hemorrhage can be minimized only by
digital pressure and early recognition.
Diagnostic Work-up Impaired by
a Cervical Collar
Cervical spine protection by means of a neck collar remains
a common practice during the prehospital transportation
of patients with PNIs. The value of this practice is ques-
tionable and may be harmful in some patients.
Consequence
Spinal immobilization may complicate the evalua-
tion and diagnostic work-up, and most importantly;
the application of a cervical collar in the presence of a
large or expanding hematoma may cause respiratory
obstruction (see Fig. 792).
Grade 1/2 complication
 812 SECTION XII: TRAUMA SURGERY
Repair
Removal of the collar.
Prevention
Cervical spine protection has absolutely no role in
patients with stab wounds to the neck. Its value in cases
with GSWs is limited. It is rare that low-velocity GSWs
result in spinal instability. In a series of 1300 patients
with GSWs of the spine, Meyer and coworkers10 found
no unstable fractures. However, it has been reported
and it is also our experience, that in rare occasions, a
low-velocity GSW can cause unstable spinal fractures
without cord injury.11 In high-velocity wounds, massive
destruction of the bone and ligament structures of the
cervical spine may cause instability. However, these
injuries are always associated with irreversible cord
destruction, making spinal immobilization of limited
practical value. It is recommended that in knife injuries,
no cervical collar is applied. In GSWs, a collar may be
applied, always monitoring for expanding hematoma or
respiratory distress. In these cases, the collar should be
loosened to relieve the airway obstruction.
Inadequate Selection of Patients
for Surgical Intervention
Consequence
Only about 17% of GSWs and 10% of stab wounds
to the neck require a therapeutic operation. Subjecting
the remaining 83% to 90% of patients to an unnecessary
operation is not an acceptable practice.
At the same time, failure to follow written protocols
and algorithms, especially in low-volume trauma centers
or by an inexperienced surgeon, may result in missing
signicant injuries
Grade 2/3 complication
Prevention/Repair
The selection of patients for operation or observation
is based on clinical examination and appropriate inves-
tigations. It is essential that clinical examination is per-
formed systematically, preferably according to a written
protocol (Box 791), and investigations are selected
with the help of an algorithm, which takes into account
the experience and resources of the individual trauma
center. Figure 794 demonstrates the algorithms that
have been in use at the Los Angeles County and
University of Southern California trauma center since
1997.
INVESTIGATIONS
The mechanism of injury and clinical examination should
determine the need and type of specic investigations in
the evaluation of PNIs. Patients with hard signs of major
vascular or laryngotracheal injuries should undergo an
operation without any delay for denitive investigations.
Box 791 Protocol for Clinical Examination in
Penetrating Injuries of the Neck
Systemic Examination
1 Dyspnea: Yes No
2 Blood pressure:
3 Pulse:
Local Examination
Vessels
1 Active bleeding: Minor Severe No bleeding
2 Hematoma: Small Large No bleeding Expanding
3 Pulsatile hematoma: Yes No
4 Peripheral pulses (compare with normal side):
Normal Diminished Absent
5 Bruit: Yes No
6 Ankle-brachial index (ABI):
Larynx-Trachea-Esophagus
1 Hemoptysis: Yes No
2 Air bubbling through wound (ask the patient to cough):
Yes No
3 Subcutaneous emphysema: Yes No
4 Pain on swallowing sputum: Yes No
Nervous System
1 Glasgow Coma Scale (GCS):
2 Localizing signs (describe):
3 Cranial nerve injury:
Facial nerve: Yes No
Glossopharyngeal nerve: Yes No
Recurrent laryngeal nerve: Yes No
Accessory nerve: Yes No
4 Spinal cord: Normal Abnormal (describe):
5 Brachial plexus injury:
Median nerve: Yes No
Ulnar nerve: Yes No
Radial nerve: Yes No
Musculocutaneous nerve: Yes No
Axillary nerve: Yes No
6 Horners syndrome: Yes No
If time permits, chest and neck lms may be helpful in
locating foreign bodies (Fig. 795) or diagnosing an asso-
ciated hemopneumothorax, which requires treatment.
There is good evidence from large prospective studies that
patients with no signs or symptoms of vascular or aerodi-
gestive injuries do not have signicant injuries requiring
treatment, and they are very unlikely to benet from
routine angiography or esophageal studies.1,12
Plain Chest and Neck Films
Chest lms should be obtained in all fairly stable patients
with PNIs in zone I or any other wounds that could have
violated the chest cavity. About 16% of GSWs and 14%
of stab wounds to the neck are associated with a hemo/
pneumothorax.1 Other important radiologic ndings
include a widened upper mediastinum (Fig. 796), which
is suspicious of a thoracic inlet vascular injury, subcutane-
ous emphysema, fractures, and missiles.
 79 MANAGEMENT OF PENETRATING NECK INJURY 813

ALGORITHM FOR EVALUATION OF PENETRATING NECK INJURIES

Clinical examination
according to protocol

Obvious significant injuries?

Severe active bleeding
Shock not responding to fluids
Absent radial pulse
Air bubbling through wound
Respiratory distress

Yes No No No

Operation Diminished peripheral pulse Hemoptysis Gunshot

Bruit Hoarseness wounds
Widened mediastinum Painful swallowing
Shotgun injuries Subcutaneous emphysema
Hematemesis CT scan with
Proximity in obtunded patient IV contrast
Yes No

Angio Hematoma
Shock responding Suspicious
to fluids tract
Proximity injury
Yes No
Yes No Yes
Angio/ Observe
Color flow Observation Esophagography swallow
Doppler (color flow Endoscopy
Doppler optional)

Definitely Indeterminate
normal CFD or poor
vessels visualization

Observe Angiogram

Figure 794 Algorithm for the evaluation of penetrating injuries to the neck.

minor carotid injuries may be different from extremity

Angiography
Angiographic evaluation of the neck vessels after PNI
remained a standard practice in many centers for many
years.1315 Sclafani and associates13 in a review of 72 asymp-
tomatic patients with proximity PNIs who underwent
routine angiography reported a high incidence of vascular
injuries. The authors suggested that routine angiography,
in asymptomatic patients with PNIs which violate the
platysma, should be the standard of care until additional
data are available.13 Since then, numerous publications
have suggested that routine angiography in asymptomatic
patients is unnecessary, has a low yield, and does not offer
any benet over physical examination and other noninva-
sive investigations.1,6,12,1619
Clinical examination alone may miss minor injuries to
the neck vessels not requiring treatment.1,17 Many studies
have suggested that clinically occult, angiographically
detected injuries have a benign prognosis and do not
require treatment.19,20 However, there is concern that
minor vascular injuries, and it might be prudent to monitor
them until complete healing. In order to address this
concern, we suggest that asymptomatic patients be evalu-
ated with a combination of clinical examination according
to a written protocol and color ow Doppler (CFD).1
Although the absence of clinical signs suggestive of
vascular trauma reliably excludes signicant injuries requir-
ing treatment (negative predictive value [NPV] 100%),1,17
the presence of soft clinical signs does not reliably identify
patients who will require an operation. It is obvious that
angiography in this group of patients has a low yield.
However, clinical examination according to a written pro-
tocol combined with CFD studies reliably diagnosed all
vascular injuries.1,17
Some surgeons suggested a policy of routine angiogra-
phy only for injuries in zones I and III, irrespective of
clinical ndings.21 Such a policy still has a very low yield
at considerable costs and patient discomfort. In summary,
angiography for PNIs should be reserved only for selected
 814 SECTION XII: TRAUMA SURGERY
Figure 795 Chest and neck lms may be helpful in locating
foreign bodies. This patient has retained bullets in zones I and III.
Figure 796 Chest x-ray in a zone I penetrating injury shows a
widened upper mediastinum, which is suspicious of a thoracic inlet
vascular injury. This patient needs angiographic evaluation.
Box 792 Indications for Conventional
Angiography
Diagnostic Indications
Inconclusive color ow Doppler (CFD) or computed
tomography (CT) angiogram
Shotgun injuries
Gunshot wounds involving the transverse foramen of the
spine
Widened upper mediastinum in zone I injuries
Therapeutic Indications (Possible Stenting or
Embolization)
Bruit on auscultation
Diminished upper extremity pulse
Persistent slow bleeding from suspected vertebral artery
injury
cases with specic diagnostic or therapeutic indications
(Box 792).
CFD
CFD has been suggested as a reliable alternative to angi-
ography in the evaluation of PNIs.1,6,8,17,2226 In a prospec-
tive study from Los Angeles, 82 hemodynamically stable
patients were clinically examined according to a written
protocol and subsequently had angiographic and CFD
evaluation. CFD diagnosed 10 of the 11 angiographically
detected injuries and missed 1 small intimal tear that did
not require treatment.17 The study concluded that the
combination of a careful clinical examination and CFD
imaging is a safe and cost-effective alternative to routine
angiography.
CFD has the disadvantage of being operator dependent
and has some limitations in the visualization of the prox-
imal left subclavian artery, especially in obese patients; the
internal carotid artery near the base of the skull; and the
segments of the vertebral artery under the bony part of
the vertebral canal.8,24
Computed Tomography
Computed tomography (CT) has become a very useful
tool in the evaluation of PNIs, especially in GSWs. At
our center, it has become the rst-line investigation in all
hemodynamically stable patients with GSWs to the neck.
The entry and exit of the bullet should be marked with
radiopaque markers and 3-mm CT cuts should be obtained
between the markers or between the entry and the retained
bullet. Identication of the bullet trajectory is very helpful
in determining the need for further invasive investigations,
such as angiography or endoscopy. Patients with trajecto-
ries away from the major vessels or the aerodigestive
structures do not need further evaluation.8 Gracias and
colleagues27 in a study of 19 patients with PNIs found
 79 MANAGEMENT OF PENETRATING NECK INJURY 815

that in 13 cases (68%), the CT scan showed trajectories

away from vital structures and no further evaluation was
required. In addition to the missile trajectory, the CT scan
may provide information about the site and nature of any
spinal fractures, involvement of the spinal cord, the pres-
ence of fragments in the spinal canal, and the presence of
any hematomas compressing the cord.8
Helical CT angiography has been used since the early
2000s for the evaluation of the major neck vessels after
PNI. The reported results are very encouraging, and CT
angiography has become an excellent initial investigation
for suspected vascular injuries.2830 Munera and cowork-
ers28 in a prospective study of 60 patients with PNIs
compared conventional angiography and helical CT angi-
ography. The performance of CT angiography was very
good, with a sensitivity of 90%, specicity 100%, positive
predictive value (PPV) 100% and NPV 98%. In another
study of 175 patients, Munera and associates29 reported
excellent results with CT angiography and suggested
that it is a valuable investigation for evaluation of sus-
pected arterial injuries of the neck. The study may have
some limitations owing to artifacts from metallic frag-
ments or excessive air in the soft tissues.30 In these cases,
conventional angiography may be necessary for accurate
evaluation.
A brain CT scan is indicated in patients with PNIs and
unexplained central neurologic decits in order to evalu-
ate for a possible anemic infarction secondary to a carotid
artery injury or an associated direct brain injury due to a
missile fragment.8
Figure 797 Esophageal studies are recommended in stable
Esophageal Studies patients with suspicious clinical signs, such as painful swallowing,
hemotemesis, or subcutaneous emphysema and in cases with a
Esophageal studies are recommended in stable patients computed tomography (CT) scan showing bullet trajectory toward
with suspicious clinical signs, such as painful swallowing, the esophagus. This patient has a signicant leak in the cervical
hemotemesis, or subcutaneous emphysema and in cases esophagus.
with a CT scan bullet trajectory toward the esophagus
(Fig. 797).
Contrast esophagography is the most commonly used 33%.33,34 We reserve exible endoscopy only for patients
study for the evaluation of the esophagus after PNIs. who cannot undergo esophagogram because of a depressed
There has been some concern that esophagography may level of consciousness or intraoperatively.
miss small esophageal injuries. In a retrospective review of Rigid esophagoscopy may be superior to exible endos-
23 cervical esophageal injuries, Armstrong and colleagues31 copy in the evaluation of the upper esophagus and is the
reported that contrast esophagography diagnosed only investigation of choice of some authors after esophagog-
62% of perforations, compared with 100% with rigid raphy.35 However, rigid esophagoscopy can be performed
esophagoscopy. This is not our experience and at our only with the patient under general anesthesia, and many
trauma center, where we have not seen any missed surgeons are not experienced with the technique. We
esophageal injuries by esophagography since 1995. The reserve this procedure only for intraoperative evaluation
technique of esophagography is important in avoiding of the esophagus.
false-negative studies. The study is rst performed with
a water-soluble contrast, such as Gastrogran. If no leak
Studies for Laryngotracheal Evaluation
is identied the study is repeated with thin barium.
Gastrogran alone may miss small injuries.32 Indications for laryngotracheal evaluation include proxim-
Esophagoscopy, if performed by an experienced endos- ity injury with soft clinical signs suspicious of airway
copist, may be a useful investigation in the evaluation injuries (minor hemoptysis, hoarseness, subcutaneous
of the cervical esophagus. Flexible endoscopy has been emphysema) or CT scan ndings showing a bullet track
shown to have an NPV of 100% but a PPV of up to near the larynx or trachea.
 816 SECTION XII: TRAUMA SURGERY
Flexible beroptic endoscopy is the investigation of
choice, and it can be performed early in the emergency
room. The most common abnormal ndings are blood
or edema in the laryngotracheal tract and vocal cord dys-
kinesia.1 However, only 20% of patients with abnormal
ndings require an operation.1,36
CONCLUSION
There have been some signicant advances in the evalua-
tion and management of PNIs. Selective nonoperative
management of penetrating injuries, including transcervi-
cal GSWs, is an important advancement. The replacement
of angiography with CFD or CT angiography is a major
diagnostic advancement. The introduction of angiographic
stenting in selected cases with carotid or subclavian artery
injuries may revolutionize the management of these inju-
ries and eliminate the need for complex surgery in many
patients.
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33. Srinivasan R, Haywood T, Horwitz B, et al. Role of
exible endoscopy in the evaluation of possible esophageal
trauma after penetrating injuries. Am J Gastroenterol
2000;95:17251729.
817
34. Flowers JL, Graham SM, Ugarte MA, et al. Flexible
endoscopy for the diagnosis of esophageal trauma.
J Trauma 1996;40:261265.
35. Weigelt JA, Thal ER, Snyder WH, et al. Diagnosis of
penetrating cervical esophageal injuries. Am J Surg 1987;
154:619622.
36. Demetriades D, Velmahos G, Asensio J. Cervical pharyn-
goesophageal and laryngotracheal injuries. World J Surg
2001;10441048.
Section XIII
PEDIATRIC SURGERY
A. Alfred Chahine, MD
Mishaps are like knives, that either serve us or cut us, as we grasp them by the blade
or the handle.James Russell Lowell
80
Malrotation, Volvulus,
and Bowel Obstruction
Philip C. Guzzetta, Jr., MD
Malrotation and
Volvulus
INTRODUCTION
Intestinal malrotation is the result of abnormal rotation
of the intestinal tract and resultant abnormal xation of
the intestine. The normal embryologic process of intesti-
nal lengthening begins at approximately 5 weeks of gesta-
tion when the gastrointestinal (GI) tract is essentially a
short straight tube with vascular supply from the superior
mesenteric artery (SMA) and the superior mesenteric vein
(SMV) (Fig. 801). As the GI tract rapidly lengthens over
the next 7 weeks, the duodenum makes its C-loop con-
guration posterior to the SMA, and the distal small bowel
and cecum lengthen and reenter the abdomen anterior to
the SMA, after a short time within the umbilical stalk, at
about the 10th week of gestation. The cecum enters in
the left upper quadrant and then rotates 270 counter-
clockwise to reach its nal destination in the right lower
quadrant. Once the rotation is completed, the intestine
should be xed in an inverted N arrangement with the
ascending colon attached to the right retroperitoneal area,
the small intestinal mesentery xed at the terminal ileum
in the right lower quadrant to the ligament of Treitz in
the left upper quadrant, and nally, the descending colon
attached to the left retroperitoneal area (Fig. 802). When
this normal rotation and xation do not occur, the cecum
typically remains in the midabdomen or left upper quad-
rant, attempted cecal xation results in band formation
across the rst and second portion of the duodenum
(Ladds bands), and the entire midgut is attached by only
a narrow band of tissue around the SMA, predisposing it
to twisting (midgut volvulus) (Fig. 803). Certain patients,
such as children with congenital heart disease and hetero-
taxia syndrome, are at increased risk for intestinal malrota-
tion.1 Other children with nonrotation of the intestine
are those with congenital diaphragmatic hernia, gastros-
chisis, and omphalocele. However, these children rarely
need operative intervention for the nonrotation because
they are rarely symptomatic and volvulus almost never
occurs in them.
It must be emphasized that, although the previous
description of intestinal malrotation is the most common
type, variations of the anomaly occur. Some patients with
radiographic ndings of malrotation may have normal
xation and little risk of volvulus, whereas ileal volvulus
can occur with normal rotation, although that is rare.2
The classic clinical presentation of a child with intestinal
malrotation is one with bilious vomiting. If the child
also has midgut volvulus, hematemesis, hematochezia,
and peritonitis may be present as late signs, but within the
 820 SECTION XIII: PEDIATRIC SURGERY

Ao.

Duodenum-
jejunum
S.M.A.

Figure 801 Schematic ventrolateral view of a 5-mm embryo.

(Reprinted with permission from Smith SD. Disorders of intestinal
rotation and xation. In Grosfeld JL, ONeill JA, Fonkalsrud EW,
Coran AG (eds): Pediatric Surgery, 6th ed. Philadelphia: Mosby
Elsevier, 2006; p 1343.)

Figure 802 Normal xation of the midgut, shaped as an inverted

N that prevents midgut volvulus. (Reprinted with permission from
Smith SD. Disorders of intestinal rotation and xation. In Grosfeld
JL, ONeill JA, Fonkalsrud EW, Coran AG (eds): Pediatric Surgery,
6th ed. Philadelphia: Mosby Elsevier, 2006; p 1346.)

Figure 803 Pathophysiology of midgut volvulus with malrota-

tion. The narrow mesenteric attachment in nonrotation (A) or
A incomplete rotation (B) predisposes the patient to midgut volvulus
B
(C). (AC, Reprinted with permission from Smith SD. Disorders
of intestinal rotation and xation. In Grosfeld JL, ONeill JA,
Fonkalsrud EW, Coran AG (eds): Pediatric Surgery, 6th ed.
C Philadelphia: Mosby Elsevier, 2006; p 1347.)

rst hours of midgut volvulus, the abdominal examination
may be deceptively benign. Approximately 60% of patients
with intestinal malrotation present in the rst week of
life, 80% in the rst month of life, and 90% in the rst
year of life, but the patient may be asymptomatic until
adulthood.3
The diagnosis of intestinal malrotation is best made by
emergent upper gastrointestinal (UGI) study when the
diagnosis is considered. A normal examination, thus ruling
out malrotation, requires that the fourth portion of the
duodenum crosses the midline to the left of the vertebra
and ascends to the level of the greater curvature of the
 80 MALROTATION, VOLVULUS, AND BOWEL OBSTRUCTION
Figure 804 Lateral view of an upper gastrointestinal study
shows intestinal malrotation with midgut volvulus. Note the cork-
screw appearance of the contrast in the duodenum.
stomach. Volvulus may be diagnosed by UGI if the
contrast forms a sharp beak at the third portion of
the duodenum without contrast passing distally, or rarely,
a corkscrew appearance of the contrast is seen at the
duodenal-jejunal junction4 (Fig. 804). Malrotation may
also be diagnosed by abdominal ultrasound or computed
tomography (CT) scan with intravenous contrast because
of an abnormal relationship between the SMA and the
SMV. However, UGI remains the most commonly used
examination.
INDICATIONS
In the symptomatic patient with malrotation, urgent
operation to correct the condition is indicated. In asymp-
tomatic patients with malrotation, elective operation to
prevent midgut volvulus is also indicated.
OPERATIVE STEPS (THE LADD
PROCEDURE) (FIG. 805)
Step 1 Procedure may be done open
laparoscopically.
821
Step 2 If there is volvulus, it is untwisted rst, in coun-
terclockwise direction, and viability of intestine
is conrmed.
Step 3 Ladds bands are excised to free duodenum; if
duodenum is accordionated by bands, duode-
num should be straightened.
Step 4 Anterior peritoneum of small intestinal mesen-
tery should be scored, taking care to avoid injur-
ing vessels and not going completely through
mesentery. This allows base of mesentery to be
widened by placing proximal small bowel into
right lower quadrant and cecum and rest of
colon into left lower quadrant. No suture xa-
tion of these newly positioned intestinal seg-
ments is done.
Step 5 Most pediatric surgeons remove the appendix
prior to placing cecum into left lower quadrant,
because future diagnosis of appendicitis would
be difcult, although Ladd originally described
procedure without appendectomy.4
COMPLICATIONS OF
THE OPERATIVE PROCEDURE
Delay in Diagnosis with Intestinal Ischemia
Consequence
The greatest risk with intestinal malrotation is that the
diagnosis will be delayed, resulting in volvulus and
ischemia of some or all of the midgut, a catastrophic
result of a correctable condition.
Grade 4/5 complication
Repair
If there is obvious ischemia of the midgut at explora-
tion, but no perforation of the intestine, most surgeons
would untwist the volvulus, release Ladds bands,
and loosely close the abdomen with a plan to reassess
the intestine with a second-look laparotomy within 24
hours. At the second procedure, all frankly necrotic
intestines should be resected and, depending upon the
overall condition of the child and the appearance of
the viable intestine, a primary anastomosis or enter-
ostomies created. Development of short gut syndrome
and all its sequelae commonly results in a full-term
infant with less than 40 cm of small intestine, particu-
larly if the viable intestine is predominantly jejunum
without an ileocecal valve, and 25 cm with an intact
ileocecal valve.
Prevention
Any child with bilious emesis unexplained by
another condition, especially in the rst month of
or life, must have an urgent UGI to rule out intestinal
malrotation.
 822 SECTION XIII: PEDIATRIC SURGERY

E
C

Figure 805 Operative correction of intestinal malrotation with midgut volvulus. A, The appearance of the viscera upon entering the
abdomen. B, The intestinal mass is delivered out of the wound and pulled downward. C, The volvulus is corrected by untwisting the
midgut in a counterclockwise direction. D, Ladds bands are lysed. E, The mesentery is widened, and the intestine is returned to
the abdomen with the duodenum straightened and coming down the right side, and the cecum (after appendectomy) is placed into the
left lower quadrant. (AE, Reprinted with permission from Smith SD. Disorders of intestinal rotation and xation. In Grosfeld JL, ONeill
JA, Fonkalsrud EW, Coran AG (eds): Pediatric Surgery, 6th ed. Philadelphia: Mosby Elsevier, 2006; p 1355.)

Repair
Recurrent Volvulus Same as for Delay in Diagnosis with Intestinal
Ischemia, earlier.
Consequence
Intestinal infarction and possible short bowel Prevention
syndrome. If the Ladd procedure is done properly and all the
Grade 3/4/5 complication preduodenal and intermesenteric bands are taken down
 80 MALROTATION, VOLVULUS, AND BOWEL OBSTRUCTION 823

and the mesentery widened, the incidence of recurrent
volvulus is less than 5%. Fixation of the intestine with
sutures does not decrease this risk, but this may slightly
increase the risk of small intestinal obstruction.5
Small Intestinal Obstruction
Because an important part of the Ladd procedure is to
widen the mesentery and encourage adhesion formation
to this area to prevent volvulus, it is no surprise that future
intestinal obstruction may occur in 5% to 10% of patients.
Small intestinal dysmotility symptoms may persist after the
Ladd procedure, especially when the procedure is done in
children older than 1 year of age who have had chronic
symptoms (>2 mo) preoperatively.6
Consequence
Intestinal ischemia and perforation.
Grade 2/3/4 complication
Repair
Standard nonoperative and potentially operative man-
agement of small intestinal obstruction.
Prevention
Avoiding placing sutures to x the intestines.
Injury of the Mesentery
During the division of the intermesenteric Ladd bands,
the mesenteric vessels can be damaged.
Consequence
Bleeding and intestinal ischemia.
Grade 2/3/4 complication
Repair
Repair of the mesenteric arteries could be attempted if
the child is of appropriate size.
Prevention
The anterior peritoneum of the small intestinal
mesentery should be scored, taking care to avoid
injuring the vessels and not going completely through
the mesentery.
obstruction have had the condition diagnosed by fetal
ultrasound and/or fetal magnetic resonance imaging. For
example, the baby with duodenal atresia is usually identi-
ed prenatally because of fetal ultrasound done in a
mother with polyhydramnios. If the intestinal obstruction
was not determined prenatally, the baby is usually diag-
nosed within the rst day of life because of abdominal
distention, bilious vomiting, and/or failure to pass meco-
nium stool. When intestinal obstruction is suspected in
a neonate, the rst diagnostic test should be plain x-ray
lms of the abdomen as kidney, ureter, and bladder
(KUB) and lateral decubitus views. Air is an excellent
contrast agent, and often, the probable cause of the
obstruction may be determined by plain lms alone.
When the obstruction is due to atresia in the duodenum
or proximal jejunum, the proximal bowel is very dilated
and there is no gas distally. If gas is in the distal bowel
with duodenal and gastric distention, there may be duo-
denal stenosis or malrotation with midgut volvulus. Distal
intestinal atresia is characterized by plain x-rays showing
diffuse dilated intestinal loops (Fig. 806) and must be
evaluated by contrast enema to determine the cause of
the distal obstruction. Other causes of congenital bowel
obstruction include malrotation, prenatal intestinal perfo-
ration, meconium ileus, congenital intra-abdominal bands

Bowel Obstruction
INTRODUCTION

Intestinal obstruction in children is either congenital or

acquired, and the evaluation and treatment depend greatly
upon which of these etiologies is the cause of the obstruc-
tion. If the obstruction is acquired, management is
dictated by whether the child has previously had an
abdominal operation and, if so, what that operation was.

Congenital Bowel Obstruction

With many of the pregnancies in the United States being Figure 806 Plain abdominal x-ray of a newborn with distal
monitored by ultrasound, many neonates with intestinal obstruction shows multiple diffuse dilated intestinal loops.
 824 SECTION XIII: PEDIATRIC SURGERY
(most often mesodiverticular bands), meconium plug
syndrome, Hirschsprungs disease, and imperforate anus.
Treatment for all neonatal bowel obstruction is operative,
with the exception of meconium plug syndrome and
meconium ileus, which may be successfully treated with
contrast enemas. The operative procedure obviously
depends upon the cause of the obstruction, but atresia is
repaired primarily with either tapering or partial resection
of the dilated proximal intestine. Because multiple atresias
occur in 15% of patients, a potential complication is to
miss a distal atresia that has no mesenteric defect (type I
atresia), which would lead to continued obstruction post-
operatively. Congenital bands are treated by operative
lysis of the bands.
Acquired Bowel Obstruction
Acquired intestinal obstruction can be due to infectious
or mechanical causes.
Infectious Bowel Obstruction
In the neonate, a common cause of abdominal distention
and an obstructive gas pattern on plain x-rays is general-
ized sepsis. Another common cause in the premature
neonate is necrotizing enterocolitis (NEC); frequently, it
is difcult to differentiate between sepsis without NEC
and sepsis due to NEC unless pneumatosis intestinalis
(Fig. 807) or free intraperitoneal is present on plain
abdominal x-rays, implying that the cause of the obstruc-
tion is NEC. In patients with NEC successfully treated
medically, approximately 15% will develop a stricture 3 to
6 weeks after the onset of the NEC,7 which presents as
feeding intolerance and an obstructive gas pattern on plain
x-rays. Although most patients with NEC have the disease
primarily in the ileum, most post-NEC strictures occur in
the colon.
Figure 807 Cross-table left lateral decubitus plain abdominal
x-ray shows pneumatosis intestinalis in a premature infant with
necrotizing enterocolitis (NEC).
In children between the ages of 6 months and 3 years,
a common cause of intestinal obstruction is intussuscep-
tion. Likely, the hypertrophic Peyer patches that act as
the lead point in intussusception are caused by a viral
gastroenteritis, which is why the children frequently have
a several-day history of diarrhea with or without vomiting
as a prodrome to the triad of symptoms of intussuscep-
tion: (1) intermittent crampy abdominal pain, (2) bilious
vomiting, and (3) bloody stools. An obstructive gas
pattern in a child of the proper age is enough to warrant
a contrast or air enema even if not all of the triad of symp-
toms of intussusception are present.
Another cause of obstruction in children older than 3
years is perforated appendicitis. One should be alert to
that possibility because the diagnostic evaluation is either
ultrasound or abdominal CT when appendicitis is consid-
ered likely rather than proceeding with air or contrast
enema, which would be indicated if intussusception was
suspected.
Recurrent Obstruction
Consequence
Intussusception has a 5% to 10% incidence of recur-
rence. Any disease that requires either an open or a
laparoscopic procedure carries some risk of mechanical
intestinal obstruction in the future, as is discussed
next.
Grade 3/4 complication
Mechanical Bowel Obstruction
The most common cause of mechanical intestinal obstruc-
tion in children, as in adults, is adhesions secondary to
previous abdominal surgery. There is some hope that
minimally invasive procedures will induce fewer adhesions
than their open counterparts, but that has not been con-
clusively determined. Two procedures that traditionally
have fairly high incidences of intestinal obstruction after
an open procedure are the Ladd procedure for intestinal
malrotation, as discussed previously, and Nissen fundopli-
cation for gastroesophageal reux. Intestinal obstruction
after a Nissen fundoplication can be devastating because
many of those procedures are done in neurologically
impaired children who cannot communicate early symp-
toms of obstruction to the parents and an intact fundo-
plication prevents them from vomiting. This closed
on both ends arrangement can rapidly lead to closed
loop obstruction, intestinal ischemia, and patient death.
Another cause of mechanical intestinal obstruction is
congenital bands, mentioned under Congenital Bowel
Obstruction, earlier, but that is a rare condition. If a
child with previous abdominal surgery presents with
vomiting (especially if the emesis is bilious) and no stool
output and has air uid levels on plain x-ray, the child
should undergo prompt volume resuscitation and abdom-
inal exploration because the risk of intestinal ischemia is
 80 MALROTATION, VOLVULUS, AND BOWEL OBSTRUCTION
high, particularly after a fundoplication. As laparoscopic
techniques have improved, minimally invasive lysis of
adhesions is being performed more frequently, but massive
intestinal distention proximal to an obstruction continues
to limit routine use of this technique in advanced mechan-
ical bowel obstruction.
Recurrent Intestinal Obstruction
due to Adhesions
Consequence
Depending upon the extensiveness of the previous lysis
of adhesions, there is about a 15% lifetime incidence of
recurrent obstruction owing to adhesions.
Grade 3 complication
Intestinal Ischemia and Intestinal Resection
Consequence
As mentioned previously, patients after open fundopli-
cation are at risk for this complication, but in anyone,
intestinal strangulation beneath an adhesive band may
lead to loss of a signicant length of intestine, resulting
in short bowel syndrome. When recognition of intesti-
nal ischemia is delayed, sepsis and death may result.
Grade 4/5 complication
825
REFERENCES
1. Choi M, Borenstein SH, Hornberger L, Langer JC.
Heterotaxia syndrome: the role of screening for intestinal
rotation abnormalities. Arch Dis Child 2005;90:813
815.
2. Kitano Y, Hashizume K, Ohkura M. Segmental small-
bowel volvulus not associated with malrotation in child-
hood. Pediatr Surg Int 1995;19:335338.
3. Ford EG, Senac MO, Srikanth MS, Weitzman JJ. Malrota-
tion of the intestine in children. Ann Surg 1992;215:172
178.
4. Ladd WE. Surgical diseases of the alimentary tract in
infants. N Engl J Med 1936;215:705708.
5. Stauffer UG, Herrmann P. Comparison of late results in
patients with corrected intestinal malrotation with and
without xation of the mesentery. J Pediatr Surg 1980;15:
912.
6. Coombs RC, Buick RG, Gornall PG, et al. Intestinal
malrotation: the role of small intestinal dysmotility in the
cause of persistent symptoms. J Pediatr Surg 1991;26:553
556.
7. Horowitz JR, Lally KP, Cheu HW, et al. Complications
after surgical intervention for necrotizing enterocolitis:
a multicenter review. J Pediatr Surg 1995;30:994
999.
81
Imperforate Anus and
Hirschsprungs Disease
A. Alfred Chahine, MD
Imperforate Anus
and Anorectal
Malformations
INTRODUCTION
Anorectal malformations (ARMs) are a complex set of
anomalies involving the development of the anorectal
region. They manifest themselves along a spectrum from
the simple membrane covering a well-formed anorectal
canal to the cloaca and other complex defects that present
a considerable challenge for reconstruction. The etiology
of ARMs is unknown. The reported incidence is about 1
in 5000 live births, with a slight male preponderance.1
Associated anomalies are common, occurring in about
50% or 60% of the patients.2 They include cardiovascular,
genitourinary, gastrointestinal, gynecologic, spinal, and
vertebral anomalies. They have been associated with
other syndromes and have been described to occur in
families.3,4
CLASSIFICATION
There are multiple historical classication schemes but
the most widely used system is currently that proposed
by Pea5,6 (Table 811). The scheme is based on a
description of the anatomy and the presence or absence
of a stula from the rectum to the urinary system. It is
different for males and females and has prognostic and
therapeutic implications. Most defects with a perineal
stula are considered low and are usually amenable to
primary repair in the newborn period if the baby is stable
and has no other underlying major issues. If no perineal
stula is detected, it usually indicates a high defect that
is best managed with a colostomy rst followed by
repair.
CLINICAL PRESENTATION AND
PREOPERATIVE PREPARATION
Some ARMs are suspected prenatally because of the pres-
ence of polyhydramnios and dilated echogenic intestinal
loops on a fetal ultrasound. The majority are detected at
birth. A careful physical examination including the ano-
rectal and genitourinary systems is essential to classify the
defect and guide the next step in management. Perineal
stulas are sometimes subepithelial in the midline raphe
of the scrotum or perineal body and not always evident
initially. In addition, because meconium is viscous, it
takes a signicant pressure within the rectum to force the
meconium through the small diameter of the stula.7 That
pressure usually builds up in the rst 24 hours after birth.
Therefore, unless the newborn is massively distended and
at risk for perforation, there should be a systematic search
for the stula in the rst 24 hours after birth. A small
gauze should be placed at the tip of the urethra to collect
any meconium in the urine. The perineal body should
be inspected again a few hours after birth to detect any
subepithelial accumulation of meconium. Concurrently,
a search for associated anomalies should be undertaken
with an echocardiogram to rule out cardiac defects, a renal
ultrasound to rule out hydronephrosis, vertebral radio-
graphs to detect spinal defects, and a spinal ultrasound to
rule out a tethered cord. In addition, esophageal atresia
should be ruled out. Just like with any other intestinal
obstruction, intravenous hydration and nasogastric decom-
pression should be initiated. Antibiotics are necessary to
prevent contamination of the urinary tract by a rectouri-
nary stula.
INDICATIONS
The mere presence of an ARM is an indication to repair it.
CHOICE OF OPERATION
The three operations available to the surgeon in the
newborn period are (1) a primary anoplasty, also called a
 828 SECTION XIII: PEDIATRIC SURGERY
Figure 811 A male newborn with a perineal stula behind a
bucket-handle skin deformity. (Courtesy of Dr. Richard Ricketts,
Emory University, Atlanta.)
Table 811 Classication of Anorectal Malformations
Males Females
Perineal stula Perineal stula
Rectourethral stula Vestibular stula
Rectovesical stula Persistent cloaca
No stula No stula
Rectal atresia Rectal atresia
Complex defects Complex defects
Modied from Pea A. Anorectal malformations. Semin Pediatr Surg
1995;4:3547.
limited posterior sagittal anorectoplasty; (2) a denitive
repair of the ARM with a pull through of the rectum,
called posterior sagittal anorectoplasty (PSARP); and (3)
a protective colostomy. The decision of which operation
to perform depends on the sex of the patient and the
complexity of the defect.7 Laparoscopic techniques have
been reported in the management of high ARMs.810 The
principles are the same as for PSARP with laparoscopic
mobilization of the rectum and division of the stula. The
short-term results seem to be equivalent to those of
PSARP, but long-term results are not yet mature enough
to allow an evidence-based comparison with PSARP.11,12
Male Patients
A male newborn with a perineal stula and no other
serious anomalies and no prematurity is a good candidate
to have a primary anoplasty without a protective colos-
tomy (Fig. 811). If a perineal stula is not detected, a
cross-table lateral radiograph with the patient in the prone
position is obtained to determine the level of the rectum.
If the rectum is above the coccyx, it is best to perform a
protective colostomy followed by an elective repair. If the
rectum ends below the coccyx, a primary PSARP could
Figure 812 A female newborn with a rectovestibular stula.
The clamp is in the stula. (Courtesy of Dr. Richard Ricketts, Emory
University, Atlanta.)
be contemplated if the patient is stable without any other
associated problems and if the surgeon is experienced.
Otherwise, it is always safest to perform a colostomy in
the newborn period, then do the denitive PSARP later.
The repair of high ARMs in the newborn period without
a protective colostomy has been reported but should be
limited to surgeons with extensive experience.13
Female Patients
Just like for males, a female newborn with a perineal stula
and no other issues is a good candidate for a primary
anoplasty. If a vestibular stula is present, a colostomy
followed by denitive repair is recommended even though
there is a recent trend of performing primary PSARP in
these situations, depending on the surgeons experience
level (Fig. 812). If the baby has only one perineal opening
visible and no separate opening for the vagina and urethra,
that patient has a cloaca and a colostomy should be per-
formed (Fig. 813). A detailed evaluation of the urinary
and gynecologic systems should be performed to rule out
severe hydronephrosis and hydrometrocolpos caused by
obstruction secondary to the small size of the common
channel. If the baby has separate openings for the urethra
and vagina and no perineal stula, a cross-table lateral
radiograph with the patient in the prone position is
 81 IMPERFORATE ANUS AND HIRSCHSPRUNGS DISEASE
Figure 813 A female newborn with a cloaca. Note the small
external genitalia. (Courtesy of Dr. Richard Ricketts, Emory
University, Atlanta.)
obtained to determine the level of the rectum. The same
algorithm as in males, as discussed earlier, would apply.
OPERATIONS
Because of the wide spectrum of ARMs, the actual opera-
tion has to be tailored to the specic defect and associated
anomalies. Therefore, we discuss only the pitfalls of the
three most common operations performed for ARMs.
ANOPLASTY OR LIMITED PSARP
Step 1 Patient is placed in prone jackknife position
Step 2 Multiple ne sutures are placed around stula at
mucocutaneous junction
Step 3 Sphincter is divided in midline
Step 4 Rectum is dissected circumferentially
Step 5 Rectum is positioned in middle of sphincter
Step 6 Rectum is attached to skin with multiple
sutures
Step 7 Perineal body is reconstructed
The Sphincter Is Divided in the Midline
Asymmetrical Division of the Sphincter
Consequence
If the muscles are not divided in the midline during
the dissection, the rectum is not surrounded by sym-
metrical amounts of muscle in its new position. This
might lead to either incontinence because of ineffective
contractions or constipation because of abnormal angu-
lation of the rectum.
Grade 2/3 complication
Repair
A reoperation via a posterior sagittal approach is
required to reposition the rectum in the middle of the
muscles.14,15
829
Figure 814 Stimulation of the sphincter muscles with a ne-
tip electrical nerve stimulator is essential to divide the muscles
in the midline and allow for symmetrical reconstruction. (Courtesy
of Dr. Phillip Guzzetta, Childrens National Medical Center,
Washington, DC.)
Prevention
Prior to making the incision, the actual boundaries of
the sphincter should be delineated with electrical stim-
ulation (Fig. 814). The incision should be made in
the middle of the delineated area, and division of the
muscle should be guided by intraoperative stimulation
of the muscle.
The Rectum Is Dissected Circumferentially
Injury to the Urethra or the Vagina
Consequence
Some anterior perineal stulas will have very intimate
contact with the urethra in males and the vagina in
females and even share a common wall with them.
During the course of the dissection of the rectum, an
injury can occur to either the urethra or the vagina.
Grade 2/3 complication
Repair
If detected intraoperatively, primary repair of the defect
is undertaken with ne absorbable sutures and the
perineal body is reconstructed to completely cover the
repair and separate it completely from the rectum. If
not detected at the time of the operation, the patient
will present with a rectourethral or rectovaginal stula.
This will need to be repaired via a reoperation.
Prevention
Placing a catheter in the urethra of a male (or the
vagina of a female) helps in its identication during the
dissection of the rectum. Meticulous dissection along
the anterior wall of the rectum will avoid an injury to
the intimately attached urethra or vagina.
 830 SECTION XIII: PEDIATRIC SURGERY
The Perineal Body Is Reconstructed
Mucosal Prolapse
Consequence
After the anoplasty, the mucosa can prolapse into the
perineum, causing local irritation and staining of the
underwear owing to excess mucus secretion. Some-
times, it interferes with anal sensation.16,17
Grade 13 complication
Repair
If minor, the prolapse does not need to be repaired. If
signicant, a local operation to trim the excess mucosa
is performed.
Prevention
During the anoplasty, the rectum should be under
slight tension so that, at the end of the operation, no
mucosa is visible.16
Dehiscence
Consequence
After an anoplasty, a dehiscence of the repair can be
supercial or deep. A supercial breakdown is usually
secondary to infection. A deep dehiscence is a break-
down of the entire rectal repair, usually secondary to
excessive tension or ischemia. Dehiscence can lead to
strictures of the neorectum or acquired atresia in the
case of a complete breakdown.17,18
Grade 24 complication
Repair
A supercial dehiscence can be treated with local wound
care and allowed to heal by secondary intention. Stric-
tures could be dilated. Acquired atresia will need to be
reoperated on.
Prevention
Complete mobilization of the rectum off the perineal
body, urethra, and/or vagina is essential to avoid
tension on the repair. The rectum depends on its intra-
mural blood supply for survival; therefore, the integrity
of the rectal wall has to be preserved as much as pos-
sible during the dissection. By not grabbing the actual
rectum and rather using the ne sutures placed at the
mucocutaneous junction to achieve uniform traction
on the rectum can achieve this. In addition, the blood
supply of the rectum has to be preserved at the time of
the colostomy formation, if a colostomy was created
previously.
Strictures
Consequence
Strictures can develop after an anorectoplasty from
ischemia, tension, or pressure from the surround-
ing muscles. They usually lead to a partial intestinal
obstruction.
Grade 3/4 complication
Repair
Mild strictures might respond to dilations. Severe ones
will need to be addressed operatively.
Prevention
The rectum should be completely dissected from all
surrounding structures including the vagina or the
urinary tract to minimize tension on it. Avoiding injury
to the rectal wall during the mobilization should pre-
serve the intramural rectal blood supply. Placing mul-
tiple ne sutures at the tip of the rectum to achieve
uniform traction on it rather than grabbing the wall
and damaging it can achieve this. Finally, a rigorous
regimen of daily sequential dilation should be taught
to the parents to counteract the natural pressure of the
sphincter muscles on the neorectum.18
COLOSTOMY
Step 1 Left lower quadrant incision
Step 2 Identifying sigmoid colon
Step 3 Mobilizing sigmoid colon
Step 4 Dividing colon
Step 5 Maturing colostomy and mucous stula
Step 6 Irrigation of mucous stula
Dividing the Colon
Prolapse
Consequence
If minor, the prolapse can be managed nonoperatively.
But if it is severe, the colostomy will need to be
revised.
Grade 13 complication
Repair
The colostomy needs to be taken down and
rematured.
Prevention
Prolapse can be essentially avoided if the colon is
divided at a spot just distal to the junction of the
descending and sigmoid colon as the sigmoid colon
becomes mobile from the retroperitoneal attachments
of the descending colon.19 In addition, the colostomy
has to be carefully matured to the edges of the fascia
circumferentially.
Maturing the Colostomy and
the Mucous Fistula
Ischemia
Consequence
Because the rectum mobilized during the anorecto-
plasty depends on its intramural blood supply, the
cephalad rectal blood supply has to be preserved while
constructing the colostomy. Otherwise, the rectum
 81 IMPERFORATE ANUS AND HIRSCHSPRUNGS DISEASE 831

is susceptible to ischemia and necrosis, leading to mucous stula will allow the colostomy appliance to be
strictures and dehiscence.17,18 placed over the colostomy only, leaving the mucous
Grade 24 complication stula out of the fecal stream altogether.

Repair PSARP
Ischemic strictures require dilations. A dehiscence of
Step 1 Patient is placed in prone jackknife position
the rectum will require a reoperation and mobilization
Step 2 Sphincter and levator muscles are divided in
of the descending colon.
midline
Step 3 Rectum is dissected circumferentially
Prevention
Step 4 Rectum is divided in midline
During the construction of the colostomy, care has to
Step 5 Rectum and stula are separated
be taken to avoid dividing the arcade supplying the
Step 6 Rectum is positioned in middle of sphincter and
distal sigmoid colon. The dissection has to remain close
levator muscles
to the wall of the sigmoid colon to avoid injuring the
Step 7 Rectum is attached to skin with multiple
blood supply.
sutures
Step 8 Perineal body is reconstructed
Irrigation of the Mucous Fistula
The same pitfalls discussed under the limited PSARP,
Dilatation of the Rectum
earlier, apply to a full PSARP. In addition, there are spe-
Consequence cic problems to avoid.
If the rectum becomes very dilated prior to the actual
anorectoplasty, it will be difcult for it to t in the The Rectum and the Fistula Are Separated
middle of the levator and sphincter muscles and will
Urethral Diverticulum
need to be tapered. In addition, a megarectum will
exacerbate the constipation that patients with ARMs Consequence
are prone to. If the stula is divided too far from the urethra, leaving
Grade 24 complication a remnant of rectum, a urethral diverticulum will
develop, leading to repeated urinary tract infections,
Repair orchidoepididymitis, urinary pseudoincontinence, and
The rectum will need to be tapered at a separate even rectal adenocarcinoma developing 30 years after
operation. repair.17,18
Grade 14 complication
Prevention
Thoroughly irrigating the mucous stula during the Repair
colostomy construction will allow the rectum to remain The diverticulum will need to be repaired at a separate
decompressed until the anorectoplasty. In addition, operation.
choosing to construct the colostomy at the sigmoid
level rather than at the transverse colon will make it Prevention
easier to decompress the rectum through the mucous The stula should be divided and closed with absorb-
stula. able sutures as close as possible to the urethra without
narrowing it.
Urinary Tract Contamination
Inability to Find the Rectum
Consequence
If there is a rectourinary stula, the urinary tract can Consequence
be contaminated by the fecal stream, putting the patient If the rectum is really high as in the case of a recto-
at risk for urinary tract infections. vesical stula, it would be unlikely to be reached from
Grade 13 complication a posterior sagittal approach. Persistent dissection to
try to nd the rectum could result in injury to the
Repair seminal vesicles, urethra, or intestines.17,20
If there is persistent contamination of the urinary tract, Grade 24 complication
the patient might require an earlier anorectoplasty or a
revision of the colostomy. Repair
A laparotomy will be required to locate the rectum in
Prevention the abdomen.
A divided colostomy provides the best protection
against spillage of fecal contents into the distal rectum. Prevention
In addition, creating a signicant bridge of skin and Prior to anorectoplasty, the anatomy of the rectum
subcutaneous tissues between the colostomy and the should be delineated by obtaining a colostogram
 832 SECTION XIII: PEDIATRIC SURGERY
Figure 815 A colostogram through the mucous stula delin-
eates the position of the rectal tip. In this patient, a rectovesical
stula is discovered. This should prompt planning of an abdominal
approach in combination with the sacral approach for the anorec-
toplasty. The metallic pellet is placed at the skin level where the
anal dimple is. (Courtesy of Dr. Clifton Leftridge, Georgetown
University Medical Center, Washington, DC.)
through the mucous stula to help locate the rectal
end. If a rectovesical stula is present (Fig. 815), an
abdominal approach to locate the rectum and divide the
stula should be planned and combined with a poste-
rior sagittal sacral approach for the anorectoplasty.
Hirschsprungs Disease
INTRODUCTION
Hirschsprungs disease (HD) is caused by the congenital
absence of ganglion cells in the myenteric and submucosal
plexuses of the intestines. Its incidence varies from 1 in
4400 to 1 in 700 live births.21,22 The aganglionosis usually
starts just proximal to the dentate line and extends in
continuity to the transition line, which is usually in the
rectosigmoid colon. There is a 4 : 1 male-to-female pre-
ponderance, except for long-segment HD in which the
ratio is reversed.23
Figure 816 A barium enema in a newborn with intestinal
obstruction shows the classic reversal of the R/S (rectum-to-
sigmoid) ratio: The sigmoid colon is larger than the rectum, and
the transition zone is at the level of the rectosigmoid junction.
(Courtesy of Dr. Clifton Leftridge, Georgetown University Medical
Center, Washington, DC.)
CLINICAL PRESENTATION AND
PREOPERATIVE PREPARATION
The classic presentation is that of a newborn with intesti-
nal obstruction: feeding intolerance, abdominal disten-
tion, failure to pass meconium spontaneously, and evidence
of a low intestinal obstruction on abdominal radiographs.
The diagnosis is initially suspected by a barium enema,
which reveals the characteristic transition zone with rever-
sal of the rectum-to-sigmoid (R/S) ratio: The rectum
should always be larger than the sigmoid. If aganglionic,
the rectum will not distend and will be smaller than
the sigmoid (Fig. 816). The diagnosis is conrmed with
a suction biopsy of the mucosa and submucosa, which
shows the aganglionosis and compensatory neuronal
hypertrophy in Meissners plexus. The initial treatment
is decompression with rectal washouts performed at the
bedside. If the washouts are successful in decompressing
the obstruction, an elective repair is contemplated. If
the transition zone is higher than can be reached by the
washouts, the decompression is going to be unsuccessful
and the patient will require a formal leveling colostomy,
in which intraoperative biopsies are serially obtained to
determine the level of ganglionosis. A divided colostomy
is then constructed at that level.
 81 IMPERFORATE ANUS AND HIRSCHSPRUNGS DISEASE
INDICATION
The presence of HD is an indication to repair it.
OPERATION
There are three classic operations to repair HD.23 They all
utilize the same principles: resecting the aganglionic intes-
tines, resecting or bypassing the rectum, maintaining con-
tinence by preserving the internal sphincter, which is also
aganglionic in HD patients.
The Swenson operation resects the aganglionic intes-
tines and rectum almost all the way to the dentate line.
The ganglionic intestine is then anastomosed to the anus
just proximal to the dentate line.
The Soave-Boley operation is an endorectal pull-
through of the ganglionic bowel. The aganglionic intes-
tine is resected to the level of the rectum below the
peritoneal reection. A submucosal dissection from both
the pelvic side and the anal side removes the rectal mucosa
and creates a muscular cuff. The ganglionic intestine is
then pulled through the cuff, and the anastomosis is
created just proximal to the anorectal verge.
The Duhamel operation leaves the rectal stump intact
after the resection of the aganglionic intestines. A retro-
rectal space is created for the ganglionic intestine. An
incision is made in the posterior rectal wall just proximal
to the dentate line, and an anastomosis is created between
the rectum and the ganglionic intestine.
All the operations just discussed have been performed
laparoscopically with good results.2430 In addition, a
transanal approach to the pull-through has emerged and
has probably become the most commonly performed
procedure for HD today.3137 Therefore, we limit the dis-
cussion of the operation and its pitfalls to this procedure,
even though all the other available operations are safe and
effective.
OPERATIVE STEPS
Step 1 Patient is placed in lithotomy position
Step 2 Anal verge is retracted circumferentially with
either sutures or retractors
Step 3 Mucosa is incised circumferentially a few milli-
meters proximal to dentate line
Step 4 Submucosal dissection proceeds, leaving muscu-
lar cuff
Step 5 At peritoneal reection, rectal cuff is divided
circumferentially to transition from submucosal
to full-thickness dissection
Step 6 Cuff is divided in midline posteriorly
Step 7 Mesentery of rectum and colon is divided
sequentially
Step 8 Full-thickness biopsies are obtained at various
levels to determine level of ganglionosis on
frozen sections.
833
Step 9 Once level is found, aganglionic bowel is resected
and ganglionic segment is pulled through cuff
Step 10 Ganglionic intestine is anastomosed in full-
thickness fashion to anorectal verge
Step 11 Laparoscopy can be performed to help
with mobilization of proximal colon and to
obtain level of ganglionosis prior to transanal
dissection
A Submucosal Dissection Proceeds,
Leaving a Muscular Cuff
Injury to the Nervi Erigentes
Consequence
While mobilizing the rectum, the nervi erigentes
can be injured, creating sexual dysfunction, includ-
ing impotence and absence of ejaculation,38 and
constipation.39
Grade 4 complication
Repair
The nervi erigentes cannot be repaired.
Prevention
Keeping the dissection very close to the muscle of the
rectum and pushing the mesorectal tissues away gently
with minimal force, as originally advocated by Swenson
and associates, will preserve the nervi erigentes.4042
The Aganglionic Bowel Is Resected and the
Ganglionic Segment Is Pulled through the Cuff
Twisting of the Pulled-through Intestines
Consequence
During the transanal mobilization of the ganglionic
bowel, a twist can occur, leading to an obstruction.
Grade 3/4 complication
Repair
A redo pull-through will be needed to straighten out
the intestines.
Prevention
During the transanal mobilization of the rectum and
colon, marking the posterior and anterior parts of the
colon sequentially will ensure that the pull-through is
straight and not twisted (Fig. 817). In addition, lapa-
roscopy can be used to conrm that the pull-through
is straight and not kinked.
Anastomotic Leak
Consequence
The incidence of leaks after pull-throughs for HD is
around 2%.36,40,43,44 Leaks will predispose to pelvic sepsis
and the late development of strictures.
Grade 24 complication
 834 SECTION XIII: PEDIATRIC SURGERY
Sutures in anterior
midline of intestine
Figure 817 Hidden anatomy: During a transanal pull-through,
marking the intestines with sequential sutures will prevent the
twisting of the intestines.
Repair
Most leaks are best treated with a diverting colostomy.
A major disruption of the anastomosis will require a
redo pull-through, especially if it is early after the initial
operation.45
Prevention
Meticulous technique during the dissection to preserve
as much of the blood supply of the pull-through as
possible is imperative. The anastomosis should be
constructed without tension.
Stricture
Consequence
There is a widely reported (0%20%) range of stricture
formation after a pull-through for HD.23 Strictures lead
to persistent obstruction and predispose the patient to
recurrent bouts of enterocolitis.36,44
Grade 24 complication
Repair
Most strictures will respond to anal dilations. Recalci-
trant strictures need to be addressed with stricturo-
plasty via a posterior sagittal approach or a redo
pull-through.46
Prevention
Avoiding leaks should decrease the rate of stricture
formation. Routine postoperative dilations in the
immediate postoperative period are being used more
frequently because the transanal pull-through is being
performed at an earlier stage when the anal canal is
smaller. Whether this will prevent stricture formation
is yet to be seen.
General Pitfalls
Incontinence
Consequence
The incidence of incontinence after a pull-through
varies widely and is more common in patients with
trisomy 21.4752 Obviously, it contributes to a decline
in the quality of life of the patients and their parents.
Grade 4 complication
Repair
The majority of patients with incontinence issues after
an HD pull-through improve with time and bowel
management programs.53,54
Prevention
No specic factor has been identied in the pathogen-
esis of incontinence after pull-through, so its preven-
tion remains elusive.
Enterocolitis
Consequence
Hirschsprungs enterocolitis is a poorly understood
phenomenon causing fevers, stool retention or
diarrhea, abdominal distention, leukocytosis, and a
sepsis-like picture.23 If untreated, it carries a signicant
mortality.
Grade 24 complication
Repair
Enterocolitis is treated with antibiotics and rectal wash-
outs. Anal dilations and injection of botulinum toxin
to relax the aganglionic anal sphincter have also been
helpful.55 Most patients with enterocolitis will eventu-
ally outgrow it without any further interventions.
Patients with recurrent recalcitrant bouts of enteroco-
litis may benet from a posterior myomectomy.56
Prevention
Rectal washouts after a pull-though have been
suggested as a way to decrease the incidence of
enterocolitis.57
Total Colonic HD
Consequence
If total colonic HD is not suspected before a transanal
dissection is undertaken, one might be forced to commit
to a choice of pull-through in the neonatal period that
is suboptimal for this very difcult problem.
Grade 3/4 complication
Repair
Multiple operations have been devised for the treat-
ment of total colonic HD, including the Kimura
right colonic patch,58,59 the Martin modication of
the Duhamel procedure,60 and the straight ileoanal
pull-through.61
 81 IMPERFORATE ANUS AND HIRSCHSPRUNGS DISEASE
Figure 818 Barium enema in a patient with total colonic
Hirschsprungs disease shows the characteristic lead piping with
blunting of both splenic and hepatic exures.
Prevention
Total colonic HD should be suspected preoperatively
and an appropriate choice of operation selected prior
to transanal dissection. Females and patients with
hereditary HD have a higher incidence of total colonic
HD. The barium enema shows a characteristic lead
piping with blunting and rounding of both splenic
and hepatic exures (Fig. 818). These patients do not
usually respond well to rectal washouts. Therefore, a
period of observation in the neonatal period with rectal
washouts to ascertain that the baby is going to thrive
and remain decompressed might be wise prior to trans-
anal pull-through.
Residual Aganglionosis
Consequence
Performing the anastomosis at a level at which the
ganglion cells are still absent will result in persistent
obstruction.
Grade 3/4 complication
Repair
A redo pull-through will need to be performed.
Prevention
The availability of reliable pathologists to recognize
ganglionic segments on frozen section is imperative.
Once a level is detected, performing the anastomosis a
few centimeters proximal to that ensures that the anas-
835
tomosis is not in the transition zone where ganglion
cells could be present but sparse.
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57. Mir E, Karaca I, Gunsar C, et al. Primary Duhamel-
Martin operations in neonates and infants. Pediatr Int
2001;43:405408.
837
58. Kimura K, Nishijima E, Muraji T, et al. A new surgical
approach to extensive aganglionosis. J Pediatr Surg
1981;16:840843.
59. Kimura K, Nishijima E, Muraji T, et al. Extensive
aganglionosis: further experience with the colonic patch
graft procedure and long-term results. J Pediatr Surg
1988;23(1 pt 2):5256.
60. Martin LW. Surgical management of Hirschsprungs
disease involving the small intestine. Arch Surg
1968;97:183189.
61. Sandegard E. Hirschsprungs disease with ganglion cell
aplasia of the colon and terminal ileum; report of a case
treated with total colectomy and ileo-anostomy. Acta Chir
Scand 1953;106:369376.
82
Pectus Excavatum
Brian J. Duffy, MD, David M. Powell, MD,
and Martin R. Eichelberger, MD
INTRODUCTION
Pectus excavatum is the most common congenital anterior
chest wall deformity, occurring in approximately 1 in 700
live births. It is characterized by depression of the sternum
and lower costal cartilages, resulting in a funnel-shaped
appearance of the anterior chest wall. The exact etiology
is unknown. Early investigators attributed the defect to
abnormal development of the diaphragm, but there has
been little evidence to support this hypothesis except for
the rare occurrence of pectus excavatum in association
with congenital diaphragmatic hernia. There is frequent
association with Marfans syndrome, an inherited disorder
that affects cartilage and other connective tissue. Approx-
imately 26% of children with pectus excavatum have tho-
racic scoliosis, and 37% have a family history of an anterior
thoracic deformity.1
In the majority of children, the abnormality becomes
apparent in the rst year of life. As the child grows,
the deformity may become progressively worse. Typical
symptoms are chest pain and exercise intolerance, attribut-
able to the restrictive effect of the deformity on the
cardiopulmonary system. Occasionally, children experi-
ence palpitations or syncope related to an underlying
cardiac abnormality, such as mitral valve prolapse. As chil-
dren become older, they become self-conscious about
their physical appearance, often prompting a surgical
evaluation.
In the early 1900s, Meyer and Sauerbrach reported the
rst operative repairs for pectus excavatum.1 In 1949,
Ravitch2 reported his technique consisting of excision of
all deformed cartilages within the perichondrium, division
of the xiphoid from the sternum, division of the intercos-
tal bundles from the sternum, and a transverse sternal
osteotomy. Since the original description by Ravitch,
several modications of the open technique have been
used successfully. In 1998, Nuss and coworkers3 reported
their technique for the minimally invasive repair of pectus
excavatum. Currently, the minimally invasive technique is
widely accepted as an alternative to the open approach.
In this chapter, both the open and the minimally
invasive repairs are discussed separately. Selection of an
approach should be based not only on the ultimate results
and long-term recurrence rates but also on the potential
complications. Factors inuencing the decision to perform
an open versus a minimally invasive pectus excavatum
repair include the severity of the defect, symmetry of
the deformity, prior failed operation, and prior cardiac
or thoracic surgery. Long-term results and recurrence
rates have yet to be reported for the minimally invasive
technique.
INDICATIONS
Chest pain, especially in area of deformed cartilages or
after sustained exercise
Palpitations, tachycardia, or syncope related to cardiac
arrhythmia
Exercise intolerance secondary to cardiopulmonary
insufciency
Prevention or correction of postural deformity
Improvement of self-image based on abnormal physical
appearance
Note: Cardiac and pulmonary insufciency in children
with pectus excavatum is controversial and difcult to
measure with current diagnostic testing, but many clini-
cians and patients report increased stamina after surgical
repair.1
Open Repair
(Modied Ravitch)
OPERATIVE STEPS
Step 1 Midline incisionnipple to xiphoid
Step 2 Skin and pectoralis muscle aps to expose
deformed costal cartilages
Step 3 Subperichondrial resection of the abnormal
costal cartilages (usually ribs two to six)
Step 4 Transverse anterior wedge osteotomy at
cephalad transition from normal to posteriorly
 840 SECTION XIII: PEDIATRIC SURGERY

displaced sternum (to facilitate elevation of

sternum)
Step 5 Division of rectus muscle from xiphoid process
Step 6 Strut xation of sternum using retrosternal
approach (Adkins strut)
Step 7 Advancement of pectoralis muscle aps to cover
sternum
Step 8 Reattachment of rectus muscle to lower
sternum
Step 9 Evacuation of air from chest cavity with red
rubber catheter
Step 10 Closure of skin incision over closed suction
drain

Subperichondral Resection of Abnormal Costal

Cartilages (Figs. 821 to 824)
Figure 822 Elevation of the cartilage with a towel clip facilitates
Damage to the Perichondrium circumferential dissection.
Consequence
Remodeling of the anterior chest wall after operation
depends upon regeneration of cartilage from the peri-
chondrium. Damage to the perichondrium impairs its
regenerative capacity.
Grade 4 complication
Repair
Simple suture repair.
Prevention
Careful dissection of the costal cartilage from its
perichondrium using specially designed perichondrial
elevators.

Damage to the Costochondral Junction

Consequence
Misalignment of the bone and cartilage during healing,
leading to chest wall asymmetry and protuberance of Figure 823 Circumferential dissection of the perichondrium
the chest wall. from the cartilage.
Grade 4 complication

Figure 821 Using a perichondrial elevator separates the peri- Figure 824 Dividing the cartilage facilitates separation at the
chondrium from the costal cartilage. costochondral junction.
 82 PECTUS EXCAVATUM 841

Repair
Simple suture repair of perichondrium to bone.
Prevention
Excise only the amount of deformed cartilage necessary
for elevation of the chest wall. Minimize dissection at
the costochondral junction.

Strut Placement for Fixation of the Sternum

(Figs. 825 to 829)
Damage to the Intercostal or Internal
Mammary Vessels
Consequence
Severe bleeding, hemothorax, or hemomediastinum.
Delayed-onset thoracodystrophy can result from isch-
emia to the sternum. Figure 827 Passing the strut through the contralateral rib
space.
Grade 25 complication
Repair
Simple ligation.

Figure 825 Metal strut used for elevation and xation of the
sternum. Figure 828 Elevation of the sternum into the nal position.

Figure 826 Using a nger to guide the strut under the

sternum. Figure 829 Wire xation of the strut.
 842 SECTION XIII: PEDIATRIC SURGERY
Prevention
Avoid detaching the perichondrium from the sternum
to help preserve the intercostal vessels. Dissect directly
adjacent to the sternum when creating the retrosternal
space for strut placement to avoid injury to the internal
mammary vessels located slightly more lateral to the
sternum.
Damage to the Heart
Consequence
Cardiac perforation, pericardial tamponade, pericarditis.
Grade 5 complication
Repair
Cardiac perforation requires emergent median ster-
notomy for relief of tamponade and repair of cardiac
injury. Pericarditis can occur postoperatively and often
resolves with nonsteroidal anti-inammatory medica-
tion. Percutaneous drainage is usually required for a
large or persistent effusion.
Prevention
Careful blunt dissection in the retrosternal space while
passing the strut, especially in a patient who has had
prior cardiothoracic surgery.
Dissection around the Pleura (Fig. 8210)
Consequence
Pneumothorax from lung or pleural injury. Injury to
the lung can result in persistent air leak and expanding
pneumothorax after operation. Isolated injury to the
parietal pleura causes pneumothorax resulting from air
trapping from the external environment, but this should
not continue to expand after closure.
Grade 1/2 complication
Repair
If there is suspicion of lung injury, insert a chest tube.
If a small injury is made to the pleura, widen the hole
Figure 8210 Evacuating air from the chest using a red rubber
catheter.
to prevent a tension pneumothorax during the opera-
tion. At the end of operation, evacuate air from the
pleural cavity using a red rubber catheter and Valsalva
maneuver followed by suture repair of the pleura.
Prevention
Careful dissection when mobilizing the perichondrium,
detaching the rectus muscle, dissecting around the
sternum, and placing the strut.
POSTOPERATIVE COMPLICATIONS
Wound Complications and Infection
Seroma formation beneath the skin aps of the anterior
chest wall can be prevented with closed suction drainage
catheters placed at the time of operation. Perioperative
antibiotic therapy helps reduce the incidence of wound
infection. Wound infection or dehiscence may lead to
infection of the metal strut, requiring long-term antibiotic
therapy. Failure of antibiotic therapy for strut infection
necessitates bar removal and delayed chest wall recon-
struction. Postoperative analgesia and pulmonary toilet
help prevent atelectasis and pneumonia.
Recurrence
If the metal strut is left in place for at least 1 year to allow
for adequate formation of new cartilage, there is a low
incidence of recurrence. Children with Marfans syndrome
are more likely to recur early, so the strut is often left in
place for longer than 1 year. Premature removal results in
depression of the sternum and recurrence of the excava-
tum. A second reconstructive procedure may be indicated,
depending on symptoms and cosmetic appearance.
Acquired Asphyxiating Thoracic Dystrophy
Abnormal growth of the chest wall can occur years after
repair and may cause severe respiratory symptoms. Haller4
report a series of 12 children who underwent open repair
at less than 4 years of age and subsequently developed
severe chest wall constriction from growth retardation.
Proposed mechanisms for limited chest wall growth are
disruption of the growth center at the costochondral junc-
tion and disruption of the vascular supply to the sternum.1
As a result, most surgeons strongly advise against repairing
a pectus deformity too early (before 4 years of age).
Minimally Invasive
Repair (Nuss)
OPERATIVE STEPS
Step 1 Width of chest is measured and correct length
bar is selected and bent to conform to desired
curvature of anterior chest wall

Step 2 Small transverse lateral thoracic skin incisions are
made bilaterally
Step 3 Skin tunnel is raised, and selected intercostal
space is entered from right under direct visual-
ization with thoracoscopy
Step 4 Introducer is passed through tunnel, posterior
to sternum and anterior to heart, to emerge
through contralateral intercostal space
Step 5 Two strands of umbilical tape are tied to end of
introducer, and introducer and strands are then
pulled back through tract
Step 6 Introducer is removed and umbilical tape is
transferred to pectus bar
Step 7 Bar is pulled through tract in a concave
conguration
Step 8 Bar is rotated 180, elevating sternum and chest
wall into normal position
Step 9 Each end of bar is secured to stabilizer plate or
chest wall (or both)
Step 10 Pneumothorax is evacuated before closing
incisions
Epidural Catheter Placement
(by Anesthesiologist) (Fig. 8211)
Transient Horners Syndrome
Consequence
Acute mechanical stress is applied to the deformed
costal cartilages and depressed sternum during opera-
tive positioning of the pectus bar. A thoracic epidural
catheter provides excellent postoperative analgesia.5
Adequate pain control with oral and intravenous med-
ication alone can be difcult to achieve in the immedi-
ate postoperative period. Inadequately controlled chest
pain impairs the ability to perform incentive spirometry
and thereby predisposes to atelectasis and pneumonia.
Use of the epidural can also cause transient Horners
syndrome.5
Grade 1 complication
Figure 8211 Epidural catheter placed by the anesthesiology
team.
82 PECTUS EXCAVATUM 843
Repair
If the epidural does not provide adequate analgesia,
a combination of oral, intravenous, and transdermal
medication (e.g., fentanyl patch) may be necessary.
Horners syndrome is transient and resolves sponta-
neously with discontinuation of the epidural medica-
tion. No cases of permanent Horners syndrome after
this operation have been reported in the literature.
Prevention
Proper placement of the epidural by a skilled
anesthesiologist.
Inserting the Introducer and Pectus Bar
(Figs. 8212 to 8215)
Injury to the Pericardium Resulting
in Pericarditis
Consequence
In a multi-institutional review of 251 cases by Hebra
and associates,6 the incidence of pericarditis was 0.4%.
Even with the use of thoracoscopy, the injury may not
be recognized at the time of operation. Signs and
symptoms include chest pain, dyspnea, malaise, fever,
lethargy, and a pericardial friction rub. Low voltage
may be present on electrocardiogram, and a pericardial
effusion may be apparent on echocardiogram. In a
series of patients by Miller and colleagues,7 one child
(1.2%) presented 1 month after repair with nonin-
fectious pericarditis requiring anti-inammatory medi-
cation and pericardiocentesis. In a more severe case,
bacterial pericarditis occurred in association with bilat-
eral empyema, ultimately requiring bar removal and
open dbridement of the pericardium.8 No deaths have
been reported from pericarditis.
Grade 1 complication
Figure 8212 Using thoracoscopy helps guide placement of the
introducer and bar.
 844 SECTION XIII: PEDIATRIC SURGERY

A
A

B
B
Figure 8214 A and B, Transthoracic placement of the intro-
Figure 8213 A, Entering the right chest with the introducer. ducer elevates the chest wall deformity in preparation for bar
Note the pectus deformity protruding inward from the anterior placement.
chest wall. B, Passing the introducer between the heart and the
sternum.

B
A
Figure 8215 A and B, Placement of the bar using thoracoscopic guidance. Note that the bar is placed initially in a concave position,
then rotated 180 into the nal position.
 82 PECTUS EXCAVATUM 845

Repair
Repair of the torn pericardium should not be attempted
at operation. Similar to the postpericardiotomy syn-
drome seen commonly after cardiac surgery, most cases
of pericarditis are transient and resolve with nonsteroi-
dal anti-inammatory medication.5 Persistent symp-
toms may respond to methylprednisolone.9 A large or
persistent pericardial effusion usually requires percuta-
neous drainage.
Prevention
Careful dissection in the retrosternal space minimizes
trauma to the pericardium. The current shape of the
introducer has helped to facilitate the dissection,
thereby decreasing the incidence of pericarditis.10

Injury to the Heart and Blood Vessels
Consequence
Cardiac perforation has been reported only once in the
literature, and it occurred while the introducer clamp
was being passed blindly across the mediastinum.10
Emergency median sternotomy, cardiac bypass, and
repair of the tricuspid valve were performed, followed
by open repair of the pectus excavatum. Injury to major
blood vessels is rare, but it includes laceration of the
internal mammary artery11 and pseudoaneurysm of the
anterior thoracic artery.6
Grade 5 complication
Repair
Emergency median sternotomy is recommended for
any cardiac injury. Intraoperative echocardiography
helps delineate concomitant valve injury. Primary repair
or ligation is the recommended treatment for blood
vessel injury.
Prevention
Careful dissection when passing the introducer and
pectus bar beneath the sternum and across the medi-
astinum. Thoracoscopy improves visualization when
passing the introducer and pectus bar between the
heart and the sternum. Jacobs and coworkers12 reported
success with the tunnel device normally used for endo-
scopic saphenous vein removal to help create the
retrosternal tunnel. A small subxiphoid incision7 and
external traction to the sternum can help facilitate
passage of the introducer and pectus bar.
Securing the Bar and Lateral Stabilizers
(Figs. 8216 to 8218)
Bar displacement
Consequence
Rotation of the bar (known as ipping) is a compli-
cation unique to the minimally invasive procedure.
Recurrence of the deformity and chest pain are the two
most common presenting features. In their original
paper, Nuss and coworkers3 reported bar displacement
Figure 8216 Proper initial measurement from midaxillary to
midaxillary line allows for correct sizing of the bar, minimizing
postoperative bar displacement.
Figure 8217 Pectus bar, pictured with two different types of
stabilizers.
in 2 of 42 children (4.8%), requiring revision. In a
questionnaire survey of pediatric surgeons, bar dis-
placement was reported as the most common complica-
tion requiring reoperation (9.2%).6
Grade 3/4 complication
Repair
Numerous reports have clearly documented the need
for reoperation for bar repositioning or removal after
displacement.7,1316 Early bar displacement is corrected
in the operating room by repositioning and xing the
bar more securely to the chest wall. Late displacement
may require removal of the bar and may necessitate
repeat operation to correct the resultant deformity.
Prevention
Selection of a bar that ts the desired contour of the
chest wall and use of the lateral stabilizer signicantly
reduce bar displacement. Since the introduction of
the lateral stabilizer, the incidence of bar displacement
has decreased from 16% to 5%.10 The following rec-
ommendations from Hebra and associates6 may help
prevent bar displacement:
1. Proper initial measurement from midaxillary to midax-
illary line, realizing that the distance will be slightly
longer (1 to 2 cm) than the bar required.
 846 SECTION XIII: PEDIATRIC SURGERY
A ment rate (0.8%).
B Repair
Figure 8218 A and B, Wire xation of the pectus bar and
stabilizer. Additional sutures are placed through the holes of the
stabilizer to improve xation.
2. Placing the transverse lateral thoracic incisions at the
midaxillary line.
3. Placing the bar at the deepest point of the excavatum
deformity with the bar crossing the sternum at a 90
angle.
4. Placement of a second bar (also with stabilizer) in older
or more active patients or those with severe deformity.
5. Securing the bar itself to the chest wall muscles (in
addition to securing the stabilizer).
6. Smooth transition from general anesthesia to conscious
sedation with minimal agitation.
7. Good posture and maintenance of a straight spine posi-
tion in the rst 30 days after operation to allow brous
tissue integration and bar stabilization.
Improper Fixation of the Stabilizer
Consequence
Increased probability of displacement. Chronic move-
ment and instability of the stabilizer cause persistent
pain and irritation of the overlying skin. Also, the
stabilizer can cause pressure on the skin with seroma
formation and aseptic dermatitis.17
Grade 3/4 complication
Repair
Resecure the stabilizer.
Prevention
Wiring the bar to the stabilizer has helped decrease the
incidence of bar displacement.5 Currently, the system
recommended by Nuss16 of wiring a stabilizer to the
bar and applying several polydioxanone (PDS) sutures
to the bar and underlying ribs on the opposite side
under thoracoscopic guidance has a very low displace-
Pneumothorax
Consequence
Through the incisions and thoracoscopy, air can be
trapped in the thoracic cavity, resulting in postoperative
pneumothorax. Injury to the lung is a rare cause of
pneumothorax. In a survey of pediatric surgeons by
Hebra and associates,6 pneumothorax requiring chest
tube was the second most common complication of
the procedure (4.8%). In a single-center experience by
Miller and colleagues,7 the most common complication
was pneumothorax (40%), but only 2 patients (2.4%)
required chest tube.
Grade 1/2 complication
Because postoperative pneumothorax mainly occurs
from air entering the chest cavity rather than from
lung injury, most will resolve spontaneously. Symp-
tomatic or enlarging pneumothorax requires tube
thoracostomy.
Prevention
A water-seal system using a rubber catheter and positive
pressure prior to closing the last incision has minimized
the incidence of pneumothorax.10 A chest radiograph
is performed immediately after operation, and again as
needed at the discretion of the surgeon to rule out
expanding pneumothorax.
POSTOPERATIVE COMPLICATIONS
Noninfectious Complications
Noninfectious complications include seroma formation,
dermatitis, and pleural effusion. Seroma or dermatitis
usually occurs at the lateral thoracic incisions from
mechanical irritation from the stabilizer and often resolve
spontaneously. If the seroma is very large, or there is
suspicion of infection, needle aspiration may be diagnostic
and therapeutic. Simple pleural effusion may occur imme-
diately after operation or in delayed fashion, but it usually
resolves spontaneously.

Infectious Complications
Perioperative antibiotic therapy should always be used
because a foreign body is being inserted into the chest.
Although infectious complications occur with low inci-
dence (2%),6 they can have serious sequelae. Supercial
wound infection, bar or stabilizer infection, pneumonia,
empyema, mediastinitis, and bacterial pericarditis have
all been documented in the literature. Supercial wound
infection often resolves with antibiotic therapy and does
not require bar removal. Bar infection is minimized by
sterile technique and applying povidone-iodine (Beta-
dine) to the incisions during insertion.10 Abscess around
the stabilizer or bar can be treated with local drainage
and intravenous antibiotic, but the stabilizer or bar may
ultimately require removal.7 Contact dermatitis with
fungal superinfection has occurred at the epidural inser-
tion site and resolved with topical therapy.14 Pneumonia
is minimized by use of perioperative antibiotics, vigor-
ous pulmonary toilet, and early return to ambulation.
Bilateral empyema and bacterial pericarditis have been
reported, requiring bar removal, pericardiocentesis, and
open dbridement of the pericardium.8 If mediasti-
nitis is present, bar removal is indicated to clear the
infection. Reoperation should be deferred for 6 to 12
months.
Rare Complications
Rare complications include cardiac arrhythmia, thoracic
outlet syndrome, acquired thoracic scoliosis, and metal
allergy. Cardiac arrhythmias presumably result from
mechanical irritation of the heart during the retrosternal
dissection and passage of the introducer and pectus bar.
Thoracic outlet syndrome has been reported in three
adolescent males who experienced persistent paresthesias
in an upper extremity after operation.8 Two resolved
spontaneously 4 weeks after operation, and one required
bar removal for persistent symptoms and bar instability.
Acquired thoracic scoliosis has been reported in two
children after the minimally invasive repair.18 In the
rst child, mild preoperative scoliosis became markedly
pronounced after surgery. Moderate improvement was
achieved with an exercise regimen and physical therapy.
In the second child, there was no preoperative scoliosis.
Scoliosis occurred after operation and showed improve-
ment with exercise and physical therapy. Asymmetrical
pneumatic pressure in the thoracic cavity and paraspinal
muscle imbalance probably contribute to acquired scolio-
sis. Metal allergy is manifest by an unrelenting skin rash
with hyperesthesia over the distribution of the bar. Nickel
allergy has been documented in the literature, but this
should be conrmed with formal allergy testing prior
to bar removal. A trial of topical steroids is appropriate,
but if bar removal becomes necessary, replacement
should be with a custom-made nonallergenic alloy such
as titanium.10
82 PECTUS EXCAVATUM 847
Asymmetry, Overcorrection, and Recurrence
Chest asymmetry prior to operation can result in a less
than optimal cosmetic result. Some surgeons recommend
against the minimally invasive repair for an asymmetrical
deformity. Overcorrection of the deformity may lead to
pectus carinatum. Mild overcorrection or carinatum has
resolved with bar removal or orthotic treatment.5 Severe
chest wall asymmetry and progressive carinatum may
require bar removal and open carinatum repair.13,14
Although short-term follow-up results after bar removal
appear promising, long-term results and recurrence
rates are not yet available for the minimally invasive
operation.
REFERENCES
1. Shamberger RC. Pectus excavatum. In Ziegler M,
Azizkhan R, Weber TR (eds): Operative Pediatric Surgery.
New York: McGraw-Hill, 2003; pp 255267.
2. Ravitch MM. The operative treatment of pectus excava-
tum. Ann Surg 1949;129:429444.
3. Nuss D, Kelly RE, Croitoru DP, Katz ME. A 10-year
review of a minimally invasive technique for the correction
of pectus excavatum. J Pediatr Surg 1998;33:545552.
4. Haller JA Jr. Severe chest wall constriction from growth
retardation after too extensive and too early (<4 years)
pectus excavatum repair: an alert. Ann Thorac Surg 1995;
60:18571858.
5. Croitoru DP, Kelly RE, Goretsky MJ, et al. Experience
and modication update for the minimally invasive Nuss
technique for pectus excavatum repair in 303 patients.
J Pediatr Surg 2002;37:437445.
6. Hebra A, Swoveland B, Egbert M, et al. Outcome analysis
of minimally invasive repair of pectus excavatum: review of
251 cases. J Pediatr Surg 2000;35:252258.
7. Miller KA, Woods RK, Sharp RJ, et al. Minimally invasive
repair of pectus excavatum: a single institution experience.
Surgery 2001;130:652659.
8. Moss RL, Albanese CT, Reynolds M. Major complications
after minimally invasive repair of pectus excavatum: case
reports. J Pediatr Surg 2001;36:155158.
9. Muensterer OJ, Schenk DS, Praun M, et al. Postpericardi-
otomy syndrome after minimally invasive pectus excava-
tum repair unresponsive to nonsteroidal anti-inammatory
treatment. Eur J Pediatr Surg 2003;13:206208.
10. Nuss D, Croitoru DP, Kelly RE, et al. Review and
discussion of the complications of minimally invasive
pectus excavatum repair. Eur J Pediatr Surg 2002;12:
230234.
11. Willekes CL, Backer CL, Mavroudis C. A 26-year review
of pectus deformity repairs, including simultaneous
intracardiac repair. Ann Thorac Surg 1999;67:511
518.
12. Jacobs JP, Quintessenza JA, Morell VO, et al. Minimally
invasive endoscopic repair of pectus excavatum. Eur J
Cardiothorac Surg 2002;21:869873.
13. Engum S, Rescorla F, West K, et al. Is the grass greener?
Early results of the Nuss procedure. J Pediatr Surg 2000;
35:246251.
 848 SECTION XIII: PEDIATRIC SURGERY
14. Molik KA, Engum SA, Rescorla FJ, et al. Pectus excava-
tum repair: experience with standard and minimal invasive
techniques. J Pediatr Surg 2001;36:324328.
15. Fonkalsrud EW, Beanes S, Hebra A, et al. Comparison of
minimally invasive and modied Ravitch pectus excavatum
repair. J Pediatr Surg 2002;37:413417.
16. Nuss D. Recent experiences with minimally invasive pectus
excavatum repair: Nuss procedure. Jpn J Thorac
Cardiovasc Surg 2005;53:338344.
17. Watanabe A, Watanabe T, Obama T, et al. The use of a
lateral stabilizer increases the incidence of wound trouble
following the Nuss procedure. Ann Thorac Surg 2004;77:
296300.
18. Niedbala A, Adams M, Boswell W, Considine J. Acquired
thoracic scoliosis following minimally invasive repair of
pectus excavatum. Am Surg 2003;69:530533.
83
Tracheoesophageal Fistula and
Esophageal Atresia Repair
Shawn D. Safford, MD and Jeffrey Lukish, MD
INTRODUCTION
Esophageal atresia (EA) occurs in approximately 1 in every
3000 to 4500 live births and has no described sex predi-
lection. EAs with and without tracheal stulas have been
classied into ve types: (1) EA with distal tracheoesoph-
ageal stula (TEF), (2) EA without TEF, (3) EA with
proximal TEF, (4) EA with proximal and distal stula, and
(5) isolated TEF (H type). EA with a TEF between the
distal esophagus and the trachea occurs in approximately
86% of cases.13 EA occurs with other signicant con-
genital anomalies in 30% to 76% of children.2,4 Impor-
tantly, these associated congenital anomalies are the major
source of morbidity and mortality associated with EA
repair.1 The most common congenital anomaly is con-
genital heart disease, which is found in up to 20% of
children.5 The acronym VACTERL groups associated
defects into vertebral, anal, cardiac, tracheoesophageal,
renal, and limb abnormalities.
Children present at various times depending on the
type of anomaly. EA prevents the child from swallowing
amniotic uid, with a resultant polyhydramnios. Prenatal
ultrasound can demonstrate polyhydramnios, absent or
small stomach bubble, and an esophageal pouch.6,7 Those
not detected prenatally become symptomatic soon after
birth with drooling, choking, and the inability to tolerate
feeding. In contrast, patients with an H-type TEF may
not be diagnosed until later in life. The diagnosis
should be suspected in a child with recurrent episodes
of aspiration pneumonia, choking, and coughing with
feedings.
The diagnosis of EA is demonstrated on chest radio-
graph showing a curved catheter in the proximal esopha-
geal pouch. In patients with an isolated EA, other ndings
include a gasless abdomen. Other studies in the work-up
may include contrast esophagogram and bronchoscopy.
Evaluation should also include echocardiogram, renal
ultrasound, and vertebral lms to rule out major cardiac,
renal, and vertebral anomalies. In addition, the echocar-
diogram will evaluate for the location of the aortic arch
to aid in planning the operation.
INDICATIONS
Newborn with blind ending upper esophageal pouch
Newborn with a gasless abdomen on plain x-ray
OPERATIVE STEPS
Step 1 Position patient for posterolateral thoracotomy
opposite aortic arch
Step 2 Division of stula tract
Step 3 Dissection of proximal esophageal pouch
Step 4 End-to-end anastomosis of proximal and distal
esophagus
OPERATIVE PROCEDURE
Posterolateral Thoracotomy
Right-sided Aortic Arch
Consequence
With the signicant association with congenital cardiac
anomalies, the location of the aortic arch is right-sided
in up to 5.4% of children.810 The location in the oppo-
site chest makes the already challenging anastomo-
sis more difcult.8 The aorta obscures the esophagus
and stula when approaching from the right chest.
Proceeding with the operation through the right chest
leads to a higher leak rate (42%) and higher morbidity
and mortality.9 Of signicance, the nding of a right-
sided aortic arch (RAA) should raise the suspicion for
the nding of a long-gap atresia. Long-gap atresias are
found in up to 42% of patients with RAA.8
Grade 3 complication
Repair
Babu and coworkers8 proposed the approach to man-
agement of RAA tracheoesophageal repairs. All infants
 850 SECTION XIII: PEDIATRIC SURGERY

should have a preoperative echocardiogram, and if Division of the Fistula

RAA is suspected, the echocardiogram should be
repeated; alternatively, magnetic resonance imaging
(MRI) is performed. When an unsuspected RAA is
found at the time of the initial exploration, the decision
to proceed is based on the anatomy and the ease of
dissection. If the dissection is difcult, a delayed left
thoracotomy should be performed after a complete
evaluation of the vascular anatomy.
Prevention
Preoperatively, all patients should undergo an extensive
work-up to diagnose an RAA including echocardio-
gram. If identied, a repeat echocardiogram or
MRI should be performed to conrm the diagnosis.
The alternate vascular abnormality of a double aortic
arch would not change the approach on the right
side.
Long Thoracic Nerve Injury
Consequence
In 89 patients undergoing thoracotomy for TEF repair,
29 (33%) had signicant musculoskeletal abnormali-
ties, and 24% demonstrated long thoracic nerve injury.11
The long thoracic nerve is purely motor and originates
from the fth to seventh cervical roots and supplies the
serratus anterior. The serratus anterior is responsible
for the abduction and elevation of the superior limb
and can act as an accessory muscle during inspiration.
Paralysis of the muscle causes winged scapula, in
which the scapula moves away from the thoracic wall,
the shoulder falls down, and the arm cannot be lifted
higher than 90 when stretched outward.
Grade 4 complication
Missed Upper Pouch Fistula
Consequence
If an upper pouch stula is missed during the dissection
of the esophageal pouch, the patient is susceptible to
recurrent aspirations.
Grade 3 complication
Repair
A missed upper pouch stula will require a reoperation
to close it via a repeat thoracotomy or a cervical incision
if it is high enough.
Prevention
A rigid bronchoscopy at the beginning of the operation
will identify the presence of an upper pouch stula and
help identify the location of the TEF (Fig. 831).
Ligation of the Fistula Too Close or
Too Far from the Trachea
Consequence
Ligation of the TEF too close to the trachea may lead
to tracheal stenosis, which may result in recurrent
pneumonias or difculty with breathing. In contrast,
dividing the stula too far from the trachea may lead
to respiratory symptoms secondary to recurrent aspira-
tions from the resultant esophageal diverticulum.16
Grade 3 complication

Repair
In most cases, serratus anterior paralysis secondary to
thoracotomy will resolve over 6 months.8 If conserva-
tive treatment is unsuccessful, the scapula will require
loose xation to the chest wall.12

Prevention
Bianchi and associates13 proposed the use of an axillary
skin crease muscle-sparing incision through the third
or fourth intercostal space. Exposure was not restricted,
scar aesthetic was excellent, and no signicant differ-
ence was found regarding duration of operation, post-
operative ventilation, or the incidence of anastomotic
stricture.14
Thoracoscopic repair has been shown to be a safe Figure 831 Rigid bronchoscopy at the beginning of the opera-
alternative when performed by experienced surgeons.15 tion would help locate the location of the tracheoesophageal stula
The thoracoscopic approach decreases the morbidity (TEF) (here proximal to the carina) and rule out the presence of
associated with the thoracotomy with no subsequent an upper pouch second stula. (Courtesy of Dr. David Powell,
increase in morbidity and/or mortality. Childrens National Medical Center, Washington, DC.)
 83 TRACHEOESOPHAGEAL FISTULA AND ESOPHAGEAL ATRESIA REPAIR 851

Proximal
esophagus
B

Membraneous
trachea

Tracheo-
esophageal
fistula

D
Figure 832 During dissection of the TEF, the stula should be circumferentially controlled and occluded. Once dissected free of sur-
rounding tissue, the stula should be ligated with a 1-mm cuff on the tracheal side (A). Ligation of the TEF too close or too far may lead
to tracheal stenosis (B) or an esophageal diverticulum (C), respectively.

Repair surrounding tissue, the stula should be ligated with a

If the patient develops recurrent aspirations in the 1-mm cuff on the tracheal side (Fig. 832).
setting of an esophageal pouch, an exploration of the
chest and excision of the pouch should be performed.
Dissection of the Proximal and Distal
For tracheal stenosis, depending on the location of the
Esophageal Pouch
stenosis, treatment options include resection, costal
cartilage grafting, and stenting.17 Esophageal/Tracheal Injury
Prevention Consequence
During dissection, the stula should be circumferen- Esophageal stricture is discussed in the section on
tially controlled and occluded. Once dissected free of Esophageal Stenosis, later.
 852 SECTION XIII: PEDIATRIC SURGERY

Esophageal disruption/anastomotic leak are discussed

in the section on Esophageal Leak, later.
Grade 3/4/5 complication
Repair
Special care must be taken during the dissection to
minimize the amount of damage to the normal esoph-
agus. If an injury occurs, primary repair should be
performed to conserve native esophagus.
Prevention
The distal esophagus is particularly susceptible to injury
during dissection. Dissection should involve locating
the proximal portion of the distal esophagus and
encircling it with a vessel loop just distal to the stula
in order to control the passage of further contents. No
further dissection of the distal esophagus should be
performed to minimize the tenuous blood supply from
segmental branches of the aorta.
In order to carry out the dissection of the proximal
esophagus and aid in its identication, the anesthesiologist
pushes against a 20-Fr catheter in the proximal esophageal
pouch. A transmural stitch placed through the stula and
incorporating the catheter also makes manipulation of the
proximal esophagus less traumatic.

Long Gap Atresia

Consequence
The nding of a long gap atresia signicantly alters the
options for repair (Fig. 833).
Grade 2/3/4 complication
Repair
Current techniques of correcting long gap atresia
include cervical esophagostomy with eventual esopha-
geal replacement, circular esophagomyotomy, bougi-
nage, esophageal reconstruction using a ap from the
proximal stump, and extrathoracic traction stitches.1821
Every effort should be made to maintain the native
esophagus because children whose native esophagus
is preserved have better swallowing function and less
gastroesophageal reux.22
If the ends of the proximal and distal esophagus cannot
be brought together, the initial maneuver would include
careful dissection of the distal end. Classic teaching dis-
courages dissection of the distal esophageal dissection, but
the risks of this have been a subject of debate. In studies
by Lessin and colleagues,23 distal esophageal dissection
allowed for primary closure without signicant morbidity.
If dissection of the distal esophageal pouch is unsuccessful,
an attempt should be made at closing the anastomosis
primarily under tension. In previous studies with ultra
long gap atresias measuring greater than 3.5 cm, none of
eight children developed anastomotic leaks, disruptions,
recurrent TEFs or deaths; however, tension did lead to a
signicant stricture rate (50%), and major gastroesopha-
geal reux disease (GERD) (63%) requiring Nissen fundu-
plication.24 Three of the strictures responded to dilation
Figure 833 Radiograph represents an infant with long gap
esophageal atresia. A nasogastric tube represents the extent of the
proximal esophageal pouch. Note the biliary dilator in the distal
esophagus representing the extent of the distal esophagus. This
child has a gap of the esophagus of 3.5 vertebral bodies. (Courtesy
of Dr. Jeff Lukish, National Naval Medical Center, Bethesda, MD.)
and one required resection. These data compare favorably
with esophagomyotomies and esophageal replacement.
When these maneuvers are unsuccessful, Livaditis
circular myotomies can be performed.25 The timing for
the myotomies has ranged from the initial operation to
2 months esophageal stretching.26,27 To create length, up
to three circular myotomies can be performed. Previous
studies in six children with myotomies reported no anas-
tomotic leak or disruption in patients.27 However, one
patient did develop a stricture that was amenable to
dilation. Esophageal motility and swallowing were no
different from children with EA who did not undergo
myotomy. Delayed complications of circular myotomies
include delayed ballooning and esophageal diverticulum
formation.28,29
If the anastomosis is still unable to be performed, the
distal esophagus should be oversewn and tacked to the
prevertebral fascia to prevent retraction. Classically, a
feeding gastrostomy and cervical esophagostomy is created
for the neonatal period; however, this invariably leads to
esophageal replacement using the colon or stomach.
Another option includes delaying the denitive surgery
until the esophagus lengthens to permit primary anasto-
 83 TRACHEOESOPHAGEAL FISTULA AND ESOPHAGEAL ATRESIA REPAIR 853

mosis by proximal pouch suction.30 Most clinicians recom-

mend continuous proximal pouch suction to reduce the
risk of aspiration, but more recently, investigators demon-
strated the safety and efcacy of intermittent suction every
10 to 30 minutes.31
Alternatively, Foker and coworkers19 described placing
two sutures through the ends of the pouches and bringing
these through the thoracic wall to be sequentially tight-
ened to create length. Postoperatively, the sutures are
lengthened approximately 1 to 2 mm daily until the
esophageal ends are in close proximity. This method has
been used to bridge gaps measuring 5.3 to 6.8 cm and
could be performed in children weighing between 3.5
and 4 kg.
Finally, a last option for a long gap atresia is replace-
ment with a colon interposition, gastric tube, or gastric
pull-up. The isoperistaltic gastric tube has been demon-
strated to have better results than the colonic transposi-
tion.32 In a series of 173 children undergoing gastric tube
transposition (127 with EA), the mortality rate was 5.2%.
The anastomotic leak rate was 12%, and only 1 of these
children did not close spontaneously. Anastomotic stric-
tures developed in 20% and only 3 of 34 children did not
respond to dilation, requiring resection. Swallowing dif-
culties were common (31%) and long lasting (16%). A
late complication of the procedure included delayed gastric Figure 834 Because the esophagus lacks serosa, the surgeon
emptying. These data are in comparison with the colonic needs to take signicant bites of the mucosa to reduce the chances
interposition, which has a mortality of 13.4%, a failure of leak. The mucosa has a characteristic whitish, heaped-up look
of graft rate of 14.3%, a leak rate of 30.3%, and stricture that should be sought for with each bite.
in 30.3%.33
ing cervical esophagostomy with gastrostomy should
End-to-end Anastomosis be performed with a planned esophageal replacement
in the future.
Esophageal Leak
Consequence Prevention
The incidence of postoperative anastomotic leak ranges The rate of esophageal anastomotic leak is reduced by
from 10% to 21%.4,3436 Leaks are usually evident by using a double-layer closure (17% vs. 6.2%)34; however,
saliva or feedings appearing in the chest tube. The leaks this lower leak rate comes at the cost of an increased
are usually small and asymptomatic secondary to the stricture rate. The minor nature of most leaks makes
extrapleural approach. If the leak is major, sepsis may the leak the lesser of complications; therefore, most
ensue and surgical intervention is required. surgeons favor a single-layered closure with higher leak
Grade 3/4/5 complication and lower stricture rates. The surgeon needs to take
signicant bites of the mucosa to reduce the chances
Repair of leak (Fig. 834). An additional protective step to
In the setting of a minor leak, one may treat nonop- reduce the signicance of a leak is to perform the repair
eratively with broad-spectrum antibiotics and chest via an extrapleural approach.
tube drainage. In contrast, a major leak usually requires
Esophageal Stenosis
prompt repair. The esophageal repair should involve
primary closure with intercostal muscle with or without Consequence
pleural patch and/or thoracic drainage.37 In seven Children with strictures usually present with gastroin-
patients with a major esophageal disruption, circumfer- testinal symptoms such as dysphasia, poor feeding, and
ential disruptions ranged from 15% to 85%. In follow emesis in 80% of cases; 8% of children present with
up of their gastrointestinal function, ve of the seven foreign body obstruction with food; and 12% present
children were tolerating oral feedings, one had severe with recurrent pneumonias secondary to aspirations.38
neurologic impairment of eating, and only one dem- The rate of esophageal stricture ranges widely from
onstrated a recurrent lead with associated mediastinitis. 18% to 50%.34,39 In order to qualify as a stricture, the
If attempted esophageal repair is unsuccessful, a divert- narrow segment of esophagus must be obstructing.
 854 SECTION XIII: PEDIATRIC SURGERY
Figure 835 Radiograph represents a barium swallow after esoph-
ageal atresia repair. Note the esophagus is nearly obstructed at the
site of the anastomosis, representing a severe stricture. (Courtesy
of Dr. Jeff Lukish, National Naval Medical Center, Bethesda, MD.)
Frequently, the proximal pouch is baggy compared
with the distal esophagus and requires a barium swallow
to establish whether the narrowing is functionally
obstructing (Fig. 835).
Grade 2/3/4 complication
Repair
Most strictures will respond to dilation and usually
present after 6 months. Those strictures that present
prior to 6 months generally require surgical interven-
tion. Multiple dilations have been shown to be neces-
sary in 26% of children during the rst 5 years of
life.40 If the strictures are resistant to repeated dilations,
resection or stricturoplasty is the best option to pre-
serve the esophagus.
To guide the surgeon in performing balloon dilation,
the stricture index (SI) may be used39:
A a
SI =
A
where A is the diameter of the lower pouch of the esoph-
agus and a is the stricture diameter.
Balloon dilation is performed for strictures that are
greater than 50% of the esophageal lumen. These can be
performed under radiographic assistance with the balloon
applying pressure to 3 atmospheres over 1 to 2 minutes,
and repeated two or three times per intervention.41 The
size of the balloon should be 2 to 5 mm larger than the
stricture, and if dilation is easily accomplished, the balloon
may be increased in size by 2 mm per step. The procedure
should be repeated weekly until the SI is less than 10%.
Prevention
Strictures result from anastomotic ischemia, leaks, and
gastroesophageal reux. The risk of anastomotic leak
increases with tension and local ischemia at the suture
line. Anastomotic strictures are more common after
repair of a gap larger than 2.5 cm, which is believed to
be secondary to the tension.38 In a subjective estimate
of the degree of tension in the end-to-end anastomosis,
surgeons reported moderate to severe tension in 60%
of cases.42 In addition to anastomotic ischemia, GERD
may play a role in the development of esophageal
strictures. Gastroesophageal reux was present in 52%
of children with strictures versus only 22% of children
without strictures.43 Management of GERD is, there-
fore, an important part of the treatment of esophageal
strictures.11
Recurrent TEF
Consequence
A recurrent TEF occurs in 3% to 12% of children
between 2 to 18 months after repair.4,34,35 Recurrent
TEF usually presents with cough, choking, recurrent
pneumonia, or cyanosis with feeding.11
Grade 3/4/5 complication
Repair
The location of the stula is usually at the location of
the original stula. These recurrences usually never
close spontaneously and will require some intervention.
Novel, less aggressive techniques for closure include
endoscopic application of brin glue.44
Prevention
Previous studies demonstrated less recurrence in
patients who have had minimal mobilization of the
esophagus, one-layer closure, and end-to-end anasto-
mosis using absorbable sutures.45 Recurrent TEFs form
more frequently when the tracheal closure and the
esophageal stula are in close proximity and in the
setting of a previous esophageal leak.46
Techniques to reduce the chances of a TEF include
pleura, intercostal muscles, or pericardial interposition
graft with minimal mobilization of the distal esophagus
and careful dissection of the esophagus from the posterior
tracheal wall.
Other Complications
GERD
Consequence
Postoperative GERD occurs in 35% to 58% of
patients.4,34,40,43 Furthermore, using an esophageal pH
 83 TRACHEOESOPHAGEAL FISTULA AND ESOPHAGEAL ATRESIA REPAIR
probe, pathologic GERD may be observed in two
thirds of children after repair.47 The presence of GERD
has been implicated in contributing to leaks, strictures,
aspiration leading to pneumonia, bronchial hyperreac-
tivity, lung damage, cyanotic spells, and failure to
thrive.4,11,43,48
Grade 2/3/4 complication
Repair
One third of patients fail medical therapy and will
require surgical correction.40 The indications for surgi-
cal repair include failure of medical management as
evidenced by persistent reux symptoms, Barretts
esophagitis, failure to thrive, stricture formation, or
aspiration secondary to reux. Options for correction
include the Toupet (a 270 wrap) or a Thal (a partial
anterior wrap). These should be considered for patients
with severe dysmotility or small stomachs. The opera-
tion should take place from 6 to 21 months after the
initial surgery.11
Prevention
GERD is the result of delayed gastric emptying, dis-
placement of the gastroesophageal junction owing to
tension, and decreased esophageal clearance in the
dysmotile esophagus.49 The surgical repair should not
be compromised for the risk of developing GERD.
Aggressive medical management should be pursued in
the setting of GERD to reduce the rate of associated
complications.
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84
Congenital Diaphragmatic Hernia
T. A. Rothenbach, MD and A. Alfred Chahine, MD

INTRODUCTION physiologic (minimal ventilator requirements and no evi-

dence of pulmonary hypertension) criteria for successful
Congenital diaphragmatic hernias (CDHs) occur in thoracoscopic repair in neonates.
approximately 1 out of every 2500 live births. The true
incidence is likely higher because some fetuses do not
survive to birth. The two most common types of CDH INDICATION
are Bochdalek (posterolateral) and Morgagni (anterior).
The development of the diaphragm defect is rst notice- Presence of a CDH
able in the 8th week of gestation. Bochdalek-type defects
tend to occur more commonly on the left than the right.
The actual pathophysiology of the CDH lies not in the OPERATIVE STEPS
physical defect, but in the resultant pulmonary hypoplasia
and hypertension that occur. The exact mechanism of Step 1 Infant is placed on operating table in supine
these physiologic responses to the CDH remains poorly position under warming lights with small roll
understood. placed under infants ank on affected side
CDH can be diagnosed by fetal sonogram. Once diag- Step 2 Prepare patient to have access to both thoracic
nosed, a work-up should ensue to rule out concomitant cavities
anomalies. This should include a chromosomal analysis Step 3 Gentle reduction of abdominal contents from
as well as evaluation of the cardiac, gastrointestinal, and chest to allow visualization of diaphragmatic
genitourinary systems. defect
Most infants present shortly after birth with respiratory Step 4 Inspection for extralobar pulmonary
distress. Immediate care includes endotracheal intubation sequestration
and placement of a nasogastric tube and central access. Step 5 Inspection for, and excision of, hernia sac
Diagnosis is conrmed by plain lm. Depending on the Step 6 Creation of tension-free closure
degree of physiologic compromise caused by the pulmo- Step 7 Placement of chest tube
nary hypoplasia and hypertension, interventions such as Step 8 Monitor pulmonary tidal volume while closing
nitric oxide administration, high-frequency oscillating abdominal wall
ventilation, and extracorporeal membrane oxygenation
(ECMO) may be necessary.
Timing for repair is determined by the infants physi-
OPERATIVE PROCEDURE
ologic condition and response to interventions. As previ-
ously stated, the pulmonary hypertension and degree of
Anesthetic Preparation
pulmonary hypoplasianot the presence of abdominal
viscera in the chestare the source of physiologic derange- Small, critically ill patients require close monitoring
ment. These realizations have led to a shift from urgent throughout the procedure. Appropriate presurgical prepa-
repair of CDH to delayed repair when the infant is stable ration includes increasing the temperature in the operat-
from a pulmonary hypertension standpoint. The timing of ing room, placing overhead warming lights on the infant,
repair of infants who require ECMO intervention remains placing an arterial line for monitoring of preductal blood
controversial. gases, nasogastric tube placement, and Foley catheter
The standard approach for repairing a CDH in neonates placement.
remains the open approach. Laparoscopic and thoraco-
scopic repairs have been reported but have been fraught
Skin Preparation of Both Thoracic Cavities
with high conversion rates, long operative times, and high
recurrence rates.14 Yang and coworkers2 suggested ana- Occasionally, these infants may develop a contralateral
tomic (presence of the stomach in the abdomen) and pneumothorax, severely compromising pulmonary
 858 SECTION XIII: PEDIATRIC SURGERY
function. This will require rapid placement of the chest
tube on the contralateral thorax.
Gentle Reduction of the Abdominal Viscera
from the Thoracic Cavity
After making a left subcostal incision, gentle downward
retraction is placed on the viscera in the thoracic cavity.
Injury to Solid Organs or Hollow Viscus Organ
Consequence
Inappropriate retraction of the small or large intestine
can lead to intramural hematomas. More commonly,
aggressive reduction of the liver and spleen can lead to
hemorrhage.
Grade 24 complication
Repair
If hematomas of small and large bowel are identied,
they should be closely inspected. If there is concern for
a full-thickness injury to the involved intestine, resec-
tion should be carried out with a primary anastomosis
in cases in which the infant is stable. The larger concern
is for potential injury to the liver and spleen. When
encountered, control of liver bleeding in a neonate is
best achieved with compression of the liver and topical
hemostatic agents. Further interventions are often more
harmful than helpful. Initial management of splenic
or renal lacerations should be handled in a similar
fashion.
Prevention
Gentle distraction of the bowel, either manually or with
the use of atraumatic forceps, will help prevent bowel
or mesenteric injury. When reducing the stomach, care
must be taken to avoid excessive stretch on the short
gastric vessels. With careful manual reduction of the
solid viscera, injury can usually be avoided. In order to
maintain the intra-abdominal position of each organ as
it is reduced, placement of laparotomy pads under
retractors can be helpful in avoiding solid organ
injury.
Inspection for Extralobar
Pulmonary Sequestration
Missed Extralobar Pulmonary Sequestration
Consequence
Two problems can arise from management of an
extralobar pulmonary sequestration associated with a
CDH. The rst complication is failure to recognize the
lesion. Approximately 10% of patients with CDH will
have a concomitant extralobar pulmonary sequestration
(Fig. 841). These are usually located along the border
of the diaphragm. The second complication is inade-
quate ligation of the blood supply to the sequestration,
leading to hemorrhage.
Grade 2/3 complication
Figure 841 Extralobar pulmonary sequestration presenting in
conjunction with a congenital diaphragmatic hernia (CDH). Failure
to recognize it intraoperatively might result in a need for a second
operation or hemorrhage if its systemic blood supply from the aorta
is not adequately controlled.
Repair
Failure to recognize a pulmonary sequestration
may result in the patient requiring a second operative
procedure later in life when the lesion becomes symp-
tomatic or is discovered under other circumstances.
Obviously, inadequate ligation of the blood supply to
a pulmonary sequestration will result in blood loss and
possible need for reexploration.
Prevention
All patients with CDH should undergo inspection for
the presence of an associated pulmonary sequestration.
When present, the blood supply should be carefully
delineated and ligated.
Inspection for, and Excision of, a Hernia Sac
Missed Hernia Sac
Up to 20% of patients with a CDH will have an associated
hernia sac covering the abdominal viscera and bulging into
the thoracic cavity.5
Consequence
The sac needs to be excised prior to closing the defect.
Failure to do so predisposes to a recurrence.6
Grade 3 complication
Repair
A recurrent CDH needs to be repaired, requiring a
repeat laparotomy or thoracotomy.
Prevention
Complete excision of the hernia sac will allow a better
closure of the defect.
Creation of a Tension-free Repair
Closure under Tension
Consequence
After the defect is inspected, the decision is made to
close the defect primarily or with a patch. Whenever
 84 CONGENITAL DIAPHRAGMATIC HERNIA 859

Posterior remnant of diaphragm

Parietal peritoneum

A Side view
Right angle clamp

B
Parietal peritoneum

Figure 842 Hidden anatomy. A, Often, the posterior remnant of the diaphragm is rolled up like a shade under a layer of parietal
peritoneum. B, It needs to be carefully unrolled to optimize the amount of diaphragm available for repair so that tension is minimized.

possible, primary closure is preferred. When necessary Prevention

to provide a tension-free repair, placement of a patch
may be required. Closure of the defect under tension
increases the risk of a recurrent hernia defect.7 The
incidence of recurrence has been reported to vary
between 5% and 50%.8
Grade 3 complication
Repair
Recurrent CDH will require reoperation. In cases of
failed primary repairs, patch closure should be consid-
ered. In patients with a failed patch closure, repair of
the defect with a latissimus dorsi ap or replacement of
the patch can be performed.9
When performing primary closure of the CDH, ade-
quate diaphragmatic remnant should be present. Often,
the remnant is rolled up like a shade under a layer of
parietal peritoneum covering the retroperitoneum5
(Fig. 842). Solid bites of tissue should be taken using
nonabsorbable suture. If an adequate remnant is not
present, closure should proceed with patch materials,
which portends a higher rate of recurrence.10 In per-
forming a patch closure, adequate native tissue should
be included in each suture. In infants with agenesis of
the diaphragm or a large defect, placement of the
sutures around the nearest rib may be necessary. Medi-
ally, the patch may need to be secured to the crus. The
 860 SECTION XIII: PEDIATRIC SURGERY
patch should not be secured to the aortic adventitia or
the esophagus.
Placement of a Chest Tube
The use of a chest tube after a CDH repair is not univer-
sal. The main benet of having one postoperatively is
in case a pneumothorax develops from the small hypoplas-
tic lung.
Suction on the Chest Tube
Consequence
After repair of a CDH, there is always an empty space
in the ipsilateral thorax because the neodiaphragm
cannot move up and the hypoplastic lung cannot expand.
It slowly lls up with uid over the rst few days. If
suction is applied on a chest tube, it will draw the very
compliant neonatal mediastinum toward the repair very
quickly, potentially causing a cardiovascular collapse.
Grade 5 complication
Repair
Suction should be removed immediately to allow the
mediastinum to spring back toward the contralateral
side.
Prevention
If a chest tube is placed, the suction port should be
covered with tape to avoid inadvertent connection to
suction.
Monitor Pulmonary Tidal Volume While Closing
the Abdominal Wall
Creation of Abdominal Compartment Syndrome
Consequence
If tidal volumes are not monitored during abdominal
wall closure, an iatrogenic abdominal compartment
syndrome could be missed. This circumstance may lead
to postoperative ventilatory problems, decreased urinary
output, and poor intra-abdominal perfusion.
Grade 2/3 complication
Repair
Operative reexploration will be required to examine
the intestinal viscera for viability and placement of an
abdominal patch.
Prevention
Communication with the anesthesiologist during the
nal stage of the procedure can help prevent this
complication. Prior to returning the intestinal viscera
to the abdomen, the surgeon should know the peak
airway pressure. As the viscera are returned to the
abdomen and the abdominal wall is closed, this variable
should continue to be checked. If airway pressures
jump precipitously or the abdominal wall feels exces-
sively tight, primary closure of the abdominal wall
should be aborted and a patch closure undertaken.
Other Complications
Chylothorax
The occurrence of a chylothorax after the repair of a CDH
has been reported.8,1114 It seems to correlate with the
need for ECMO,11 the use of a prosthetic patch,11,12 and
the presence of a hernia sac.13 It is probably related to
abnormal mediastinal lymphatics rather than to a direct
injury during repair.8 Regardless of the pathogenesis
of chylothorax, it invariably responds to nonoperative
medical therapy.1114
Grade 1 complication
REFERENCES
1. Knight CG, Gidell KM, Lanning D, et al. Laparoscopic
Morgagni hernia repair in children using robotic instru-
ments. J Laparoendosc Adv Surg Tech A 2005;15:482
486.
2. Yang EY, Allmendinger N, Johnson SM, et al. Neonatal
thoracoscopic repair of congenital diaphragmatic hernia:
selection criteria for successful outcome. J Pediatr Surg
2005;40:13691375.
3. Holcomb GW 3rd, Ostlie DJ, Miller KA. Laparoscopic
patch repair of diaphragmatic hernias with Surgisis.
J Pediatr Surg 2005;40:E1E5.
4. Arca MJ, Barnhart DC, Lelli JL Jr., et al. Early experience
with minimally invasive repair of congenital diaphragmatic
hernias: results and lessons learned. J Pediatr Surg 2003;
38:15631568.
5. Stolar CJ, Dillon PW. Congenital diaphragmatic hernia
and eventration. In Grosfeld JL, ONeill JA Jr, Coran AG,
et al (eds): Pediatric Surgery, Vol 1. Philadelphia: Mosby
Elsevier, 2006; pp 931954.
6. Puri P. Congenital diaphragmatic hernia. Curr Probl Surg
1994;31:787846.
7. Rowe DH, Stolar CJ. Recurrent diaphragmatic hernia.
Semin Pediatr Surg 2003;12:107109.
8. Cullen ML. Congenital diaphragmatic hernia: operative
considerations. Semin Pediatr Surg 1996;5:243248.
9. Saltzman DA, Ennis JS, Mehall JR, et al. Recurrent
congenital diaphragmatic hernia: a novel repair. J Pediatr
Surg 2001;36:17681769.
10. Moss RL, Chen CM, Harrison MR. Prosthetic patch
durability in congenital diaphragmatic hernia: a long-term
follow-up study. J Pediatr Surg 2001;36:152154.
11. Hanekamp MN, Tjin ADGC, van Hoek-Ottenkamp WG,
et al. Does V-A ECMO increase the likelihood of
chylothorax after congenital diaphragmatic hernia repair?
J Pediatr Surg 2003;38:971974.
12. Oshio T, Matsumura C. Chylothorax following Bochdalek
herniorrhaphy in an infant. J Pediatr Surg 1983;18:298
299.
13. Kavvadia V, Greenough A, Davenport M, et al. Chylotho-
rax after repair of congenital diaphragmatic herniarisk
factors and morbidity. J Pediatr Surg 1998;33:500502.
14. Naik S, Greenough A, Zhang YX, Davenport M. Predic-
tion of morbidity during infancy after repair of congenital
diaphragmatic hernia. J Pediatr Surg 1996;31:16511654.
85
Wilms Tumor and Neuroblastoma
Todd A. Ponsky, MD
Wilms Tumor
INTRODUCTION
Nephroblastoma, also known as Wilms tumor after
Max Wilms who described seven cases in 1899, is the
most common intra-abdominal cancer in children. Wilms
tumor represents 6% of all pediatric cancers and the inci-
dence is 8 cases per 1 million children younger than 15
years of age or 1 in 10,000 infants.1 Seventy-ve percent
of cases occur in children under 5 years of age, and the
peak incidence is 2 to 3 years of age.2
Surgical therapy for Wilms tumor was rst described
in 1877, with poor outcomes. Over the next 100 years,
the operative strategy for Wilms tumor was modied to
include the addition of chemotherapy and, occasionally,
radiation. Furthermore, a cooperative study of several
groups called the National Wilms Tumor Study (NWTS)
developed treatment standards that have improved overall
survival to approximately 95.6% for stage 1 tumors.3
Children suspected of having a renal mass should
undergo an abdominal ultrasound (US). Besides conrm-
ing the presence of the tumor, abdominal US is necessary
to assess contralateral disease and evidence of caval inva-
sion. Chest x-ray should be performed to assess for meta-
static disease.
INDICATIONS
Renal mass on computed tomography (CT) or US
scan
OPERATIVE STEPS
Step 1 Position patient with affected side elevated on
roll
Step 2 Transverse abdominal incision
Step 3 Thorough abdominal exploration, reection of
colon off of tumor
Step 4 Exploration of contralateral kidney
Step 5 Ligation of hilar vessels
Step 6 Division of lateral attachments
Step 7 Separation of kidney from adjacent organs
Step 8 Perinephric lymph nodes dissection
Step 9 Ureter ligation
Step 10 Removal of kidney and abdominal wall closure
OPERATIVE PROCEDURE
Incision
Poor Exposure/Tumor Spillage
Prior to incision, the involved side should be slightly
elevated with a roll. The optimal incision for Wilms tumor
is a transverse abdominal incision, which offers the best
exposure. A large incision is crucial in order to avoid
excessive tumor manipulation and potential tumor spill.
Flank incisions offer suboptimal exposure.
Consequence
Poor exposure may lead to excessive tumor manipula-
tion, which may lead to tumor rupture and spillage.
Spillage of tumor will automatically upgrade the tumor
to stage 3, which will require postoperative radiation
and the addition of doxorubicin (Adriamycin) to the
chemotherapy regimen.
Grade 4 complication
Repair
If the initial incision offers poor exposure, it would be
prudent to extend the incision rather than struggle.
Once spillage occurs, there is no remedy.
Prevention
Poor exposure can be prevented by elevating the
affected side with a roll and creating a generous trans-
verse incision.
Exploration of the Contralateral Kidney
Contralateral Wilms Tumor
Identied Intraoperatively
Although controversial, many surgeons will explore the
contralateral kidney prior to nephrectomy. Gerotas fascia
is incised, the kidney is palpated and visually inspected on
all sides, and any lesions are biopsied.
 862 SECTION XIII: PEDIATRIC SURGERY
Consequence
Occasionally, contralateral tumor that was not visual-
ized on preoperative studies is identied intraopera-
tively. This may require a complete change in the
anticipated management.
Grade 3 complication
Repair
If a mass is identied in the contralateral kidney intra-
operatively, it should be biopsied. If the biopsy con-
rms Wilms tumor, the operation should be aborted
and neoadjuvant chemotherapy should be performed.
Prevention
Preoperative US and CT scans should signicantly
reduce the chance of a contralateral tumor being
identied intraoperatively.
Renal Hilum Ligation
Ligation of the Contralateral Vessels
Sometimes, the large renal mass encroaches on the hilum
so much that it thins out the inferior vena cava (IVC) and
the ipsilateral renal artery and vein and lifts the contralat-
eral renal vessels up, making them susceptible to injury or
ligation (Fig. 851).
Renal mass
Right kidney
Right renal vein
Consequence
Ischemia of the contralateral normal kidney.
Grade 4 complication
Repair
Repair of the injury can be attempted. Bypass of the
contralateral renal vessels might be necessary if the
injury was crushing or extensive.
Prevention
It is essential to completely identify both sets of renal
vessels and their junction with the IVC and aorta to
avoid inadvertent injury to the contralateral vessels.
Tumor Spillage
Ideally, the renal vein is ligated prior to tumor manipula-
tion. However, large tumors may make early vein ligation
prohibitively unsafe. Attempts at early vein ligation in the
face of poor exposure may lead to tumor spillage. Although
some investigators speculated that delayed vein ligation
may increase the chance of pulmonary embolism,4,5 results
from the NWTS-1 and -2 showed that delayed renal vein
ligation did not lead to a worse outcome when compared
with early vein ligation.6
Left renal vein
Superior
mesentery artery
Figure 851 Hidden anatomy.
Abdominal aorta When a right renal mass extends
into the hilum, it attens the
short right renal vein and lifts up
the longer left renal vein. This
puts the latter at risk for being
mistaken for the right renal vein
Inferior vena cava and ligated inadvertently.
 85 WILMS TUMOR AND NEUROBLASTOMA
Consequence
Poor exposure of the renal vein may lead to excessive
tumor manipulation and tumor rupture and spillage.
Spillage of tumor will automatically upgrade the tumor
to stage 3, which will require postoperative radiation
and the addition of doxorubicin (Adriamycin) to the
chemotherapy regimen.
Grade 4 complication
Repair
Once spillage occurs, there is no remedy.
Prevention
If a large renal mass prevents optimal exposure of the
renal vein, vein ligation should be delayed until after
the mass has been mobilized.
Intravascular Extension
Bleeding/Pulmonary Tumor Embolism
Occasionally, extension of the tumor into the renal vein
or the IVC is identied on preoperative imaging studies.
If the proximal extent of the tumor thrombus can
be palpated, proximal and distal control of the IVC is
obtained, a venotomy is performed, and the thrombus
is removed. If the proximal extent cannot be identied,
an alternative approach is necessary. Some surgeons will
perform a venotomy without proximal control and suck
the thrombus out of the IVC. Others may remove the
thrombus after placing the patient on cardiopulmonary
bypass. Tumor thrombectomy may be complicated by
bleeding and pulmonary embolism.
Consequence
Care must be taken to ensure that the proximal extent
of the tumor thrombus is identied prior to placing the
proximal clamp on the IVC or embolism may occur.
Attempts at removing a high thrombus with proximal
control may lead to signicant bleeding.
Grade 4/5 complication
Repair
Hypoxia, hypotension, and decreased end-tidal
CO2 after placement of the proximal caval clamp are
highly suspicious of a pulmonary tumor embolism.
If hypoxia and hypotension persist, median sterno-
tomy, cardiopulmonary bypass, and pulmonary artery
thrombectomy may be necessary. Some centers may
utilize uoroscopic suction thrombectomy through
the IVC.
Prevention
Preoperative Doppler US may help identify renal
or IVC involvement. The proximal extent may be
visualized, which will help to plan the operative
approach. Neoadjuvant chemotherapy is very effective
at shrinking or often completely eliminating tumor
thrombus.
863
Division of Lateral Renal Attachments/
Perinephric Lymph Node Biopsy/Dissection of
the Kidney off of the Surrounding Organs
Injury to the Surrounding Organs
After control of the renal hilum is achieved, the kidney is
separated from its surrounding attachments. First, the
lateral attachments are divided, and then the kidney is
separated from the surrounding organs. If the tumor is
involving a surrounding organ such as the liver or dia-
phragm, it should be resected en bloc if this can be done
safely.
Consequence
En-bloc resection of involved organs may be more
hazardous than leaving tumor behind. For example,
resection of a major segment of liver may lead to sig-
nicant bleeding, and pancreatic resection may lead to
a pancreatic stula.
Grade 3/4 complication
Repair
If there is any question regarding the safety of en-bloc
resection, tumor should be left behind and treated with
chemotherapy and radiation.
Prevention
Preoperative CT scans may help identify or suggest
surrounding organ involvement and help to plan the
operation.
Neuroblastoma
INTRODUCTION
Neuroblastoma is the most common solid malignancy in
childhood. Because it is a tumor of neural crest cell origin,
the tumor can develop anywhere along the path of neural
crest cell migration.7,8 Fifty percent of neuroblastomas are
found in the adrenal medulla, 25% in the paraspinal
ganglia, 20% in the posterior mediastinum, and 5% in the
neck or pelvis.911
Most cases of neuroblastoma present as an abdominal
mass. Twenty-ve percent of children present with hyper-
tension as a result of the catecholamines secreted from
the tumor.9 Forty percent of patients are younger than 1
year, 35% are aged 1 to 2 years, and 25% are older than
2 years. More than 40% of patients present with metastatic
disease.8 Children who present with localized disease have
a good prognosis (90% 3-year survival), whereas children
who present with metastatic disease have 20% 5-year
survival.
Curative resection is the goal of therapy for children
with localized disease. Children with regional spread or
metastatic disease will require surgical biopsy, but primary
therapy consists of chemotherapy and radiation.
 864 SECTION XIII: PEDIATRIC SURGERY

INDICATIONS

Surgical resection is indicated if the mass appears to be

resectable on preoperative imaging. If there is evidence Claw sign
that the mass has neurovascular invasion or if it appears
that the mass cannot be completely resected, resection
should not be attempted. In these situations, open
surgical biopsy should be performed for histologic
conrmation.

OPERATIVE STEPS

The steps of the operation vary depending on where the

mass is located. In general, however, a generous incision
to ensure adequate exposure is performed. Adequate
proximal and distal control of any involved vessels should
be attained prior to attempts at resection.

Figure 852 This tumor appears to be emanating from the kidney

OPERATIVE PROCEDURE
Pitfalls specic to neuroblastoma resection are discussed
here.
Resection versus Biopsy Alone
Preoperative Confusion of a Neuroblastoma
with Wilms Tumor
Unlike Wilms tumor, neuroblastoma is frequently
adherent to its surrounding structures, making resection
prohibitive. Therefore, if a CT scan reveals that the tumor
is adherent to blood vessels or spinal components, attempts
at resection should be avoided and a simple biopsy should
be performed for neoadjuvant chemotherapy. However,
Wilms tumor is often nonadherent and respectable,
even though it may appear to be in close proximity to
major vessels. Therefore, the approach to a Wilms tumor
may be different than that for a neuroblastoma. Therefore,
it is important to differentiate neuroblastoma from
Wilms tumor on CT scan. This can be very difcult,
especially in an adrenal-based neuroblastoma. Sometimes,
a neuroblastoma may look very similar to the classic claw
sign seen with Wilms tumor. The claw sign is the name
given to the CT scan nding in which the kidney claws
around the tumor, suggesting that the tumor is arising
from the kidney rather than externally compressing it
(Fig. 852).
Consequence
Excessive bleeding or major injury to surround-
ing structures when attempts are made at resection
because the neuroblastoma was believed to be Wilms
tumor.
Grade 35 complication
as a Wilms tumor. In fact, this is a neuroblastoma that was believed
to be a Wilms tumor and attempts were made at resection. Notice
the claw shape of the kidney that is classic for a Wilms tumor.
Repair
In cases of excessive bleeding, the abdomen can be
packed and closed and the patient should be brought
to the intensive care unit.
Prevention
Careful examination of the CT looking for signs of
neuroblastoma such as calcications will help distin-
guish Wilms tumor from neuroblastoma. Some may
argue that any tumor that appears to be distorting
major vessels should be only biopsied at rst.
Resection
Vascular Injury
Because neuroblastoma often involves the aortocaval
window and the central visceral vessels (celiac and superior
and inferior mesenteric arteries), attempts at resecting a
tumor that has vascular involvement may lead to critical
and sometimes fatal vascular injury.
Consequence
Tissue ischemia or hemorrhage.
Grade 35 complication
Repair
If vascular injury occurs, primary anastomosis or repair
with a polytetrauoroethylene (PTFE) graft may be
possible.
Prevention
Any tumor with ANY suggestion of vascular involve-
ment on preoperative imaging should probably be
 85 WILMS TUMOR AND NEUROBLASTOMA
IVC Portal vein
Figure 853 A large mass on the right is clearly distorting the
inferior vena cava (IVC) and portal vein.
SMA
Figure 854 A large mass is involving the superior mesenteric
artery (SMA).
treated with primary chemotherapy prior to attempts
at resection (Figs. 853 to 855). It is recommended
to identify the anterior surface of the aorta away from
the tumor and proceed along its adventitia to identify
the root of the central visceral arteries. If this cannot
be done safely, the resection should be aborted and a
simple biopsy performed prior to closure.
865
Aorta
Figure 855 A large mass is involving the aorta.
REFERENCES
1. Bernstein L, Linet M, Smith M. Renal tumors. In Gurney
J (ed): Cancer Incidence and Survival among Children
and Adolescents: United States SEER Program 1975
1995. Bethesda, MD: National Cancer Institute, 1999;
pp 7990.
2. Davidoff A, Shochat S. Nephroblastoma (Wilms tumor).
In Weber TR (ed): Operative Pediatric Surgery. New
York: McGraw-Hill Professional, 2003; pp 1169
1180.
3. DAngio G, Breslow N, Beckwith J. Treatment of Wilms
tumor: results of the Third National Wilms Tumor Study.
Cancer 1989;64:349360.
4. Shurin S. Fatal intraoperative pulmonary embolism of
Wilms tumor. J Pediatr 1982;101:559.
5. Akyon M, Arsian G. Pulmonary embolism during surgery
for Wilms tumour (nephroblastoma). Case report. Br J
Anaesth 1981;59:903.
6. Leape L, Breslow N. The surgical treatment of Wilms
tumor: results of the National Wilms Tumor Study. Ann
Surg 1978;187:351.
7. Wright J. Neurocytoma or neuroblastoma, a kind of
tumor not generally recognized. J Exp Med 1910;12:
556561.
8. Davidoff A. Neuroblastoma. In Oldham K (ed): Principles
and Practice of Pediatric Surgery, Vol 1. Philadelphia:
Lippincott Williams & Wilkins, 2005; pp 571593.
9. Grosfeld JL. Neuroblastoma. In ONeill J (ed):
Pediatric Surgery, Vol 1. St. Louis: Mosby, 1998;
pp 405419.
10. Grosfeld JL, Baehner RL. Neuroblastoma: an analysis of
160 cases. World J Surg 1980;4:2937.
11. Gerson JM, Chatten J, Eisman S. Familial neuroblastoma:
a follow-up. Letter. N Engl J Med 1974;290:1487.
86
Inguinal and Umbilical Hernias
Earl Hodin, MD

Repair
Inguinal Hernia Once severed, these nerves cannot be repaired in chil-
dren; if entrapped, reoperation with release or division
INTRODUCTION may be necessary.

Inguinal herniorrhaphy is one of the most common oper- Prevention

ations performed by the pediatric surgeon. Inguinal Lifting up of the aponeurosis during the division and
hernias in children are indirect, a result of a patent proces- careful identication during dissection.
sus vaginalis.
Separation of the Hernia Sac
INDICATION Damage to the Vas Deferens
Consequence
Presence of inguinal hernia in child
Infertility is unlikely if only one vas has been
An inguinal hernia in a child warrants repair to avoid the damaged.
risk of incarceration. Unlike umbilical hernias in children, Grade 4 complication
inguinal hernias do not close spontaneously.
Repair
Primary repair should be attempted but, in smaller
OPERATIVE STEPS children, can be challenging. Successful repairs and
fertility have been reported after puberty and in
Step 1 Inguinal crease incision adulthood.14
Step 2 Division of Scarpas fascia
Step 3 Opening of external oblique aponeurosis Prevention
Step 4 Isolation of spermatic cord When dissecting the hernia sac, the vas must be care-
Step 5 Separation of hernia from cord contents to fully identied and protected. A clamp should not be
internal ring applied to the sac before the vas is identied. The vas
Step 6 Division of sac and vessels should be gently teased away from the sac
Step 7 Contralateral laparoscopic exploration, if war- and never grasped with a forceps. Merely picking up
ranted (favored in some institutions) the vas with forceps has been shown to lead to brotic
Step 8 High ligation of sac luminal occlusion in rats.5,6
Step 9 Closure of external oblique aponeurosis and
Damage to the Spermatic Vessels
Scarpas fascia
Consequence
Ischemic orchitis and atrophy of the affected testicle.7
External Oblique Aponeurosis Division Grade 4 complication
Ilioinguinal and Iliohypogastric Nerve Injury
Repair
Consequence The spermatic vessels in children are too small to
Although division of these nerves may lead to a small repair.
area of anesthesia, entrapment by a suture can lead to
signicant paresthesias, which can be considerably more Prevention
troublesome. Careful, atraumatic dissection of the cord; the use of
Grade 4 complication magnifying lenses can be helpful.
 868 SECTION XIII: PEDIATRIC SURGERY

High Ligation of the Sac Prevention

Inspecting the anteromedial wall of the hernia sac prior
Tear in the Sac
to high ligation will prevent injuries to sliding organs.
Consequence If present, the transxion and ligation of the sac should
Hernia recurrence.7 be distal to the sliding organ, and consideration should
Grade 3 complication be given to narrowing the internal ring if needed.

Repair
The sac should be repaired with a ne suture if a tear
is discovered.
Prevention
Tears are common in the premature or ex-premature
infant with a large, thin sac. It is a good idea to open
the dissected sac prior to nal ligation to ascertain that
the entire circumference of the sac is being incorpo-
rated in the ligature.
Injury to Sliding Organs
Pelvic organs such as the bladder, cecum, appendix,
sigmoid colon, and fallopian tubes can form part of
the anteromedial wall of the hernia sac as a sliding
component.
Consequence
When the sac is ligated high at the internal ring,
these sliding organs can be ligated or lacerated7
(Fig. 861).
Grade 3/4 complication
Laparoscopic Contralateral Exploration
This technique is employed in some centers as a means
for assessing the need for contralateral repair.
Incomplete Evacuation of
the Pneumoperitoneum
Consequence
Subcutaneous emphysema and hernia recurrence.8
Grade 3 complication
Repair
The sac should be reopened and the pneumoperito-
neum evacuated.
Prevention
The pneumoperitoneum should be evacuated thor-
oughly prior to closing the sac with the patient in the
Trendelenburg position, a Valsalva maneuver per-
formed by the anesthesiologist, and the internal ring
stented open.

Repair Closure of the External Oblique Aponeurosis

Injuries to sliding organs are usually detected postop-
Entrapment of the Cremaster
eratively and require further procedures.
Consequence
Iatrogenic or acquired undescended testicle.9
Grade 3 complication

Repair
If an iatrogenic undescended testis occurs, an orchio-
pexy will be required.

Prevention
If cremaster is incorporated in the aponeurotic closure
sutures, the inevitable postoperative scarring may actu-
ally serve to withdraw the testis into the canal or x a
testis left in the canal. Therefore, the cremaster should
be separated from the undersurface of the external
oblique prior to its repair. At the end of the procedure,
it should be ascertained that the testis has been replaced
in the scrotum.

Other Complications
Figure 861 Hidden anatomy. The fallopian tube or any other Iatrogenic Direct Inguinal Hernia
pelvic organs can be incorporated into the anteromedial wall of the
hernia sac and injured during the transxion and high ligation. If Consequence
there is a sliding component, the ligation should be distal to the Iatrogenic direct inguinal hernia.7
sliding organ. Grade 3 complication
 86 INGUINAL AND UMBILICAL HERNIAS 869

Repair
The direct hernia should be repaired by any of several
accepted techniques.
Prevention
Although a direct hernia may rarely be seen in infants
and children, a normal posterior inguinal wall may feel
weak to the inexperienced operator. If, in a misguided
attempt to shore up this structure, one or more sutures
are placed in it, they can serve only to weaken what was
actually quite normal. Because the only procedure nec-
essary to correct the congenital inguinal hernia is a high
ligation of the patent processus vaginalis, an attempt at
repair of the inguinal oor is to be condemned.

Umbilical Hernia
Figure 862 Hidden anatomy. Violation of the umbilical hernia
INTRODUCTION sac during dissection can result in injury to loops of intestine resid-
ing in the sac.
Umbilical hernias are very common in children. Most
close spontaneously by age 4 or 5 years. The rate of incar- Prevention
ceration is very low. The dissection of the sac should be patient and method-
ical to ensure that the sac is completely dissected off
the surrounding subcutaneous tissues rather than
INDICATION pierced by the dissecting instrument. Despite this, the
sac may occasionally still be entered. Therefore, the
Persistence of an umbilical hernia after age 4 or 5
patient should be completely relaxed during this phase
years
of the procedure, allowing the intestine to drop away.
The persistence of an umbilical hernia after age 4 or 5 This, in turn, is best ensured by the use of deep, endo-
years warrants repair to prevent incarceration in the tracheal general anesthesia.
future.
Closure
Hematoma
OPERATIVE STEPS
Consequence
Step 1 Infra-umbilical incision Infection and hernia recurrence.
Step 2 Dissection of hernia sac Grade 1/3 complication
Step 3 Excision of hernia sac
Step 4 Repair of defect Repair
Step 5 Umbilicoplasty if necessary Infected wounds will usually need to be opened; recur-
Step 6 Skin closure rences will require repeat repair.

Dissection of the Hernia Sac Prevention

Careful hemostasis should be achieved prior to closure.
Violation of the Sac
A carefully constructed pressure dressing should be
Consequence carefully applied after closure and left in place for at
Intestinal injury. The sac is commonly entered during least several days.
its blunt dissection. If bowel is present in the sac at the
time, particularly bowel under tension, it may be inad-
REFERENCES
vertently pierced (Fig. 862). If unrecognized, it can
be disastrous. 1. Weber CH. Successful restoration of fertility twenty-nine
Grade 2/3 complication years after bilateral vasal injury in infancy. Urology 1986;
28:299300.
Repair 2. Pryor JL, Fusia T, Mercer M, et al. Injury to the pre-
An intestinal injury should be repaired primarily if at pubertal vas deferens. II. Experimental repair. J Urol 1991;
all possible. 146:477480.
 870 SECTION XIII: PEDIATRIC SURGERY
3. Pryor JL, Mills SE, Howards SS. Injury to the pre-pubertal
vas deferens. I. Histological analysis of pre-pubertal human
vas. J Urol 1991;146:473476.
4. Sheynkin YR, Hendin BN, Schlegel PN, Goldstein M.
Microsurgical repair of iatrogenic injury to the vas deferens.
J Urol 1998;159:139141.
5. Abasiyanik A, Guvenc H, Yavuzer D, et al. The effect of
iatrogenic vas deferens injury on fertility in an experimental
rat model. J Pediatr Surg 1997;32:11441146.
6. Shandling B, Janik JS. The vulnerability of the vas deferens.
J Pediatr Surg 1981;16:461464.
7. Meier AH, Ricketts RR. Surgical complications of inguinal
and abdominal wall hernias. Semin Pediatr Surg 2003;12:
8388.
8. Benjamin LC, Chahine AA. Forceful evacuation of retained
pneumoperitoneum mimics an acute recurrent inguinal
hernia. J Laparoendosc Adv Surg Tech A 2005;15:487
488.
9. Donaldson KM, Tong SY, Hutson JM. Prevalence of late
orchidopexy is consistent with some undescended testes
being acquired. Indian J Pediatr 1996;63:725729.
87
Pyloromyotomy
Aziz Merchant, MD and Kurt D. Newman, MD

INTRODUCTION INDICATIONS

Infantile hypertrophic pyloric stenosis (HPS) is a common Persistent, nonbilious emesis.

condition of infancy that is easily corrected by surgery. Palpation of thickened pylorus or demonstration of
The overall annual incidence ranges from 8.2 to 12.3 cases pyloric stenosis on ultrasound
per 1000 live births.1 The classic presentation is that
of nonbilious, projectile vomiting in a 2- to 8-week-old
newborn. The vomiting results in a contraction alkalosis
OPERATIVE STEPS
secondary to severe dehydration. Sonographic identica-
tion of a thickened and lengthened pylorus helps to
Laparoscopic
solidify the diagnosis. The gold standard of treatment
is the open pyloromyotomy described by Fredet in 19082 Step 1 Position and trocar placement
and modied by Ramstedt in 1912.3 An overall complica- Step 2 Lateral retraction of stomach
tion rate of 10% (4% intraoperative and 6% postoperative) Step 3 Hypertrophied pylorus relative to duodenum
has been reported, with complications including duodenal visualized
mucosal perforation, wound infection,4 and postoperative Step 4 Incision made in pylorus
vomiting.5 Step 5 Hypertrophied bers split down to mucosa using
Eighty years after the conventional open procedure the laparoscopic pyloric spreader
was introduced, laparoscopic pyloromyotomy (LPM) was Step 6 Pylorus halves tested for independent mobility
described.6,7 Over the ensuing years, the minimally inva- Step 7 Check for mucosal perforation
sive approach has gained widespread use and acceptance. Step 8 Trocar removal and closure
Complication rates of 3% to 18% have been reported for
LPM.811 These complications have included mucosal per-
Open Pyloromyotomy
foration, incomplete pyloromyotomy, serosal laceration,
conversion to open pyloromyotomy, and wound compli- Step 1 Incision is made in right upper quadrant or
cations. Perceived advantages of LPM, including excellent supraumbilical
visualization, shorter time to full feeds, shorter length of Step 2 Fascia is opened
stay, and superior cosmesis compared with the open Step 3 Stomach and pylorus are delivered gently
surgery, have made LPM a mainstay of the pediatric surgi- through wound
cal armamentarium. Step 4 Hypertrophied pylorus relative to duodenum
Preoperatively, patients may present with a hypochlore- visualized
mic, metabolic alkalosis due to vomiting and will generally Step 5 Incision made in pylorus
be dehydrated. Aggressive resuscitation and stabilization Step 6 Hypertrophied bers split down to mucosa using
with a normalized urine output is important prior to sur- pyloric spreader and tapered back of knife
gical treatment of the disease. The bicarbonate level must Step 7 Pylorus halves tested for independent mobility
be normalized through administration of a saline solution, Step 8 Check for mucosal perforation
because infants with a metabolic alkalosis will respond Step 9 Closure
with a respiratory acidosis resulting in postoperative apnea.
Postoperatively, patients can be advanced on a feeding
regimen or ad libitum. Postoperative emesis with feedings PREOPERATIVE MANAGEMENT
is frequent but self-limiting in most cases.
This chapter discusses the preoperative, intraoperative, A good outcome after pyloromyotomy is predicated upon
and postoperative management and pitfalls of both pylo- adequate preoperative resuscitation. Children with HPS
romyotomy procedures. will usually present with a hypokalemic, hypochloremic
 872 SECTION XIII: PEDIATRIC SURGERY
metabolic alkalosis. The severity of uid and electrolyte
abnormality is reected by carbon dioxide12 levels, with
increased severity correlating with higher levels in the
blood. Five percent dextrose and 0.45 normal saline solu-
tion sufces in most cases, delivered at 1.5 to 2 times
maintenance rate with an initial bolus of 20 ml/kg of the
childs weight. The uid is supplemented with potassium
if the renal function is normal. Approximately 20% to 36%
of infants with pyloric stenosis may present with nonclas-
sic hyperkalemia and 12% to 18% with acidosis instead of
alkalosis.13 Fluid resuscitation is again paramount.
DIAGNOSIS AND ERRORS
Preoperative work-up of projectile nonbilious emesis
involves a careful history and physical examination,
drawing a basic metabolic blood panel with bicarbonate
and chloride values and, in most instances, obtaining an
ultrasound. The sensitivity and specicity of physical
examination alone was found to be 72% and 97%, whereas
that of ultrasound was 97% and 100%.14 However, false
positives on ultrasound resulting in negative laparotomy
were reported at an incidence of 0.7% to 5.3%.15,16
OPERATIVE PROCEDURE
Trocar Insertion
See Section I, Chapter 7, Laparoscopic Surgery.
Retraction of the Stomach and Duodenum
Stomach Perforation/Laceration
(Laparoscopic and Open)
Consequence
Intra-abdominal sepsis.
Grade 3/4/5 complication
Repair
Experienced laparoscopists may choose to repair a
laceration or perforation intracorporeally. Otherwise,
conversion to an open procedure may be necessary to
repair the injury. Postoperative gastric decompression
with nasogastric suction, intravenous hydration, and
perioperative and postoperative antibiotics are impor-
tant adjuncts of treatment. Injury during an open pylo-
romyotomy is less common than with LPM; however,
repair of the injury requires a similar approach as out-
lined previously.
Prevention
Improper grasping of the stomach, including inade-
quate purchase, forceful retraction, and/or careless
maneuvering, may result in serosal laceration or, more
dangerously, mucosal perforation. If undetected or
with delayed detection, the child may become very ill
from intra-abdominal sepsis. Use of Babcock clamps
and atraumatic graspers during this step will minimize
untoward complications. In addition, rm but gentle
technique for retraction is required for a successful
operation. An analysis of errors during LPM revealed
that most hollow viscus injuries are due to movements
involving excessive force or depth. Therefore, accurate
and precise movements are of utmost importance
during laparoscopic surgery in small infants.
Incision of the Pylorus and Spreading
of the Muscle Layer
Mucosal Pyloric Perforation
(Laparoscopic and Open)
Consequence
Hollow viscus injury with leak and peritonitis.
Grade 3/4/5 complication
Repair
Repair can be carried out laparoscopically or by con-
version to an open procedure depending on surgeon
comfort level and experience. There are two approaches
to repair. Traditionally, one may repair the injury with
mucosal and muscular reapproximation, followed by
sufcient rotation of the pylorus and repyloromyotomy.
Alternatively, simple mucosal reapproximation, without
muscular closure and repyloromyotomy, can be per-
formed to maintain the currently performed myotomy.
Both approaches have shown equal efcacy for repair.
Rates of hospital stay, time to feeding, and postopera-
tive complications were the same regardless of the type
of repair, and both repairs are regarded as widely
acceptable.17
Prevention
A 21-year retrospective study revealed a mucosal per-
foration rate of 1.7%.17 Excellent visualization of the
pylorus is paramount during this step. Stable and effec-
tive retraction of the stomach or duodenum will assist
in visualization and dissection. During incision of the
pylorus, small controlled movements should be per-
formed. An effective incision length of approximately
2 cm was found to be adequate in an analysis of 171
LPMs for pyloric stenosis.18 The incision should stop
just before the prepyloric vein of Mayo to avoid injur-
ing the mucosa of the duodenal recess at the distal end
of the pylorus (Fig. 871). A retractable blade instru-
ment can minimize accidental punctures. Moreover, a
guarded electrocautery blade may be used for the inci-
sion, which will provide better visualization secondary
to better hemostasis. One must be aware of electro-
cautery thermal injury to bowel, which may manifest
postoperatively as a delayed bowel injury and possible
perforation. In addition, forceful and deep spreading
of the muscle bers of the pylorus can result in perfo-
ration through the mucosa. The tips of the spreader

Figure 871 Hidden anatomy. The pyloromyotomy incision
should stop just before the prepyloric vein of Mayo to avoid injur-
ing the mucosa of the duodenal recess at the distal end of the
pylorus.
should be pushed in just enough to engage the muscle
with the serrations on the outside of the jaws (Fig.
872). To conrm mucosal integrity after spreading,
one insufates the stomach with air (120180 cc).
Green froth at the pyloromyotomy site is a sign of
mucosal perforation.
Incomplete Pyloromyotomy
(Laparoscopic and Open)
Consequence
Recurrent or persistent postpyloromyotomy vomiting,
dehydration, and possible reoperation.
Grade 2/3 complication
Repair
Patients present with persistent vomiting after pyloro-
myotomy. Radiographic studies may show continued
obstruction with a thin pyloric channel, except that
surrounding muscle layers will be thinned out. Patients
can be observed with intravenous hydration in the hos-
pital, and many of these cases will resolve. Alternatively,
in the face of persistent vomiting, dehydration, and
weight loss, reoperation is necessary. Balloon dilation
of failed pyloromyotomies has also been described.19
Prevention
Most cases of incomplete pyloromyotomy occur sec-
ondary to inadequate length of division across the
pylorus or inadequate depth through the muscle bers.
One great disadvantage of LPM compared with the
87 PYLOROMYOTOMY 873
Figure 872 Hidden anatomy. In order to avoid a mucosal per-
foration during the spreading of the bers of the hypertrophied
pylorus, the tips of the spreader should be pushed in just enough
to engage the muscle with the serrations on the outside of
the jaws.
open procedure is the lack of haptic manipulation to
judge whether the pylorus has been adequately spread.
A length of 2 cm across the pylorus has been found to
be adequate according to a recent retrospective study
of laparoscopic procedures.18 The pylorus should be
divided completely from the pyloroduodenal junction
to 1 cm beyond the antral fold proximally. The two
halves of the split pylorus should be tested for indepen-
dent motion. Failed pyloromyotomy can be attributed
to the laparoscopic learning curve, differences in
movement associated with laparoscopic procedures
compared with open ones, and inadequate retraction
of the stomach and duodenum resulting in poor visu-
alization of the pylorus.
Postoperative Complications
Persistent Vomiting
Postoperative vomiting after pyloromyotomy is fairly
common, ranging from 36% to 90% in certain series.4
However, Campbell and coworkers4 considered postop-
erative vomiting a complication if hospital stay is extended
beyond 48 hours. Using this denition, only 3.5% of cases
in their series had this complication. In rare cases, reop-
eration is required owing to incomplete surgery in the rst
operation.5,20
Grade 1/2 complication
 874 SECTION XIII: PEDIATRIC SURGERY
Wound Complications
Wound complications occur in approximately 1% of cases
and include wound infections and hematoma. Technical
complications and patient disease (e.g., hemophilia) can
affect this outcome. Choice of incision for open surgery
has not been shown to make a difference.9 Incisional
hernias are rare in pediatric laparoscopy; however, they
have been reported with open pyloromyotomy at a rate
of 0.5% to 1.5%.21,22 Rates reported in the literature
approximate 1.2%.23
Grade 2/3 complication
POSTOPERATIVE CARE AND
FEEDING REGIMENS
Postoperative feeding regimens vary widely based on local
practice and surgeon preference. Traditionally, complex
feeding regimens involved a long period of NPO after the
operation followed by graded increases or decreases in
formula volume and strength based on tolerance or intol-
erance of feeds. Ad libitum feeding regimens were shown
in cohort studies to be cost-effective with shorter length
of stays and statistically insignicant changes in postop-
erative emesis compared with complex feeding regimens.24
In addition, ad libitum feeds have been shown to decrease
the time to full feeds after pyloromyotomy without sig-
nicant increases in rates of readmission for vomiting.25,26
Early feeding (<8 hr after the operation) resulted in sig-
nicant increases in postfeeding emesis and signicantly
longer lengths of stay compared with traditional timing of
feeds (>12 hr after the operation).27,28 Randomized clini-
cal trials have not been performed to assess which method
of feeding is better, and both strict feeding regimens and
ad libitum feeding are successfully used by pediatric
surgeons after pyloromyotomy.
Persistent postoperative emesis, feeding intolerance,
and distress may be associated with complications such as
a failed pyloromyotomy, perforation, or other source of
intra-abdominal sepsis. One must maintain a high degree
of suspicion for these problems to be identied. Labora-
tory and radiologic studies, in addition to clinical suspi-
cion, will assist in the diagnosis. Prompt resuscitation
along with operative or nonoperative management may
be required for resolution. A meta-analysis of 11,003
procedures performed in this country revealed a postop-
erative complication rate of 2.7%, including perforation,
wound infection, and failed procedures with persistent
vomiting.1
REFERENCES
1. Safford SD, Pietrobon R, Safford KM, et al. A study of
11,003 patients with hypertrophic pyloric stenosis and the
association between surgeon and hospital volume and
outcomes. J Pediatr Surg 2005;40:967972.
2. Dufour H, Freaei P. La stenose hypertrophique du pylore
chez le nourisson et son traitement chirurgical. Rev Chir
1908;37:208.
3. Ramstedt C. Zur Operation der angeborenen pyloruste-
nose. Med Klin 1912;8:17021705.
4. Rao N, Youngson GG. Wound sepsis following Ramstedt
pyloromyotomy. Br J Surg 1989;76:11441146.
5. Hulka F, Harrison MW, Campbell TJ, Campbell JR.
Complications of pyloromyotomy for infantile hypertro-
phic pyloric stenosis. Am J Surg 1997;173:450452.
6. Alain JL, Grousseau D, Terrier G. Extramucosal pyloro-
myotomy by laparoscopy. Surg Endosc 1991;5:174
175.
7. Alain JL, Moulies D, Longis B, et al. Pyloric stenosis in
infants. New surgical approaches. Ann Pediatr (Paris)
1991;38:630632.
8. Hendrickson RJ, Yu S, Bruny JL, et al. Early experience
with laparoscopic pyloromyotomy in a teaching institu-
tion. JSLS 2005;9:386388.
9. Kim SS, Lau ST, Lee SL, Waldhausen JH. The learning
curve associated with laparoscopic pyloromyotomy.
J Laparoendosc Adv Surg Tech A 2005;15:474477.
10. Kim SS, Lau ST, Lee SL, et al. Pyloromyotomy: a
comparison of laparoscopic, circumumbilical, and right
upper quadrant operative techniques. J Am Coll Surg
2005;201:6670.
11. Hall NJ, Van Der Zee J, Tan HL, Pierro A. Meta-analysis
of laparoscopic versus open pyloromyotomy. Ann Surg
2004;240:774778.
12. Benson CD, Alpern EB. Preoperative and postoperative
care of congenital pyloric stenosis. Arch Surg 1957;75:
877.
13. Schwartz D, Connelly NR, Manikantan P, Nichols JH.
Hyperkalemia and pyloric stenosis. Anesth Analg 2003;
97:355357
14. Misra D, Akhter A, Potts SR, et al. Pyloric stenosis: is
over-reliance on ultrasound scans leading to negative
explorations? Eur J Pediatr Surg 1997;7:328330.
15. Godbole P, Sprigg A, Dickson JA, Lin PC. Ultrasound
compared with clinical examination in infantile hypertro-
phic pyloric stenosis. Arch Dis Child 1996;75:335
337.
16. Neilson D, Hollman AS. The ultrasonic diagnosis of
infantile hypertrophic pyloric stenosis: technique and
accuracy. Clin Radiol 1994;49:246247.
17. Royal RE, Linz DN, Gruppo DL, Ziegler MM. Repair of
mucosal perforation during pyloromyotomy: surgeons
choice. J Pediatr Surg 1995;30:14301432.
18. Ostlie DJ, Woodall CE, Wade KR, et al. An effective pylo-
romyotomy length in infants undergoing laparoscopic
pyloromyotomy. Surgery 2004;136:827832.
19. Khoshoo V, Noel RA, LaGarde D, et al. Endoscopic
balloon dilatation of failed pyloromyotomy in young
infants. J Pediatr Gastroenterol Nutr 1996;23:447
451.
20. van Heurn LW, Vos P, Sie G. Recurrent vomiting after
successful pyloromyotomy. Pediatr Surg Int 1999;15:385
386.
21. van den Ende ED, Allema JH, Hazebroek FW, Breslau
PJ. Can pyloromyotomy for infantile hypertrophic pyloric
stenosis be performed in any hospital?: results from two
teaching hospitals. Eur J Pediatr 2006:166:553557.

22. St. Peter SD, Holcomb GW 3rd, Calkins CM, et al. Open
versus laparoscopic pyloromyotomy for pyloric stenosis:
a prospective, randomized trial. Ann Surg 2006;244:363
370.
23. Ure BM, Bax NM, van der Zee DC. Laparoscopy in
infants and children: a prospective study on feasibility and
the impact on routine surgery. J Pediatr Surg 2000;35:
11701173.
24. Puapong D, Kahng D, Ko A, Applebaum H. Ad
libitum feeding: safely improving the cost-effectiveness
of pyloromyotomy. J Pediatr Surg 2002;37:1667
1668.
87 PYLOROMYOTOMY 875
25. Garza JJ, Morash D, Dzakovic A, et al. Ad libitum
feeding decreases hospital stay for neonates after pyloro-
myotomy. J Pediatr Surg 2002;37:493495.
26. Carpenter RO, Schaffer RL, Maeso CE, et al. Postopera-
tive ad lib feeding for hypertrophic pyloric stenosis.
J Pediatr Surg 1999;34:959961.
27. Van der Bilt JD, Kramer WL, van der Zee DC, Bax NM.
Early feeding after laparoscopic pyloromyotomy: the pros
and cons. Surg Endosc 2004;18:746748.
28. Lee AC, Munro FD, MacKinlay GA. An audit of post-
pyloromyotomy feeding regimens. Eur J Pediatr Surg
2001;11:1214.
Index
Note: Page numbers followed by f refer to gures; page numbers followed by t refer to tables; page numbers followed by b refer to boxes.
A Abdominal perineal resection (Continued)
Abdomen
chest tube placement in, 139, 140f
compartment syndrome of, 803, 805806
laparotomy and, 8991, 90f, 91f
injury to. See also Damage control surgery
femoral venous cannula with, 765766
gastrostomy and, 148
hemorrhage with, 763
jejunostomy and, 155
thoracic trauma and, 775
postlaparotomy abscess of, 9294, 93f
Abdominal adhesions
damage control surgery and, 806
laparoscopic gastric bypass and, 202
laparotomy and, 7172, 7374, 74f
Abdominal aortic aneurysm
elective repair of, 604610
aortoenteric stula after, 609
bleeding with, 609
common iliac vein injury with, 607609
dissection and clamping for, 598, 605
607, 605f, 606f, 607f, 608f
distal embolization with, 607
graft occlusion after, 609
horseshoe kidney and, 610
indications for, 604
infection after, 609
inferior vena cava injury with, 607609
in inammatory disease, 610
peritoneal reection for, 605
proximal neck friability in, 609
pseudoaneurysm after, 609610
renal artery reimplantation in, 610
retroaortic left renal vein and, 610
right suprainguinal incision for, 604605,
605f
steps in, 604
in suprarenal disease, 610
ureteral injury with, 609
endovascular therapy for, 654655
access failure with, 654
device fatigue with, 654
endoleaks with, 654655, 654f, 655f
inammatory, 610
rupture of
ischemic colitis with, 611
repair of, 610611
suprarenal, 610
Abdominal compartment syndrome, 803,
805806
laparotomy and, 8991, 90f, 91f
Abdominal perineal resection, 291297
abdominal dissection for, 291292
colostomy creation for, 295297, 295f,
296f
leakage from, 297
obesity and, 297, 297f
parastomal hernia with, 297
stomal necrosis with, 295296
stomal stenosis with, 297, 297f
indications for, 291
perineal dissection for, 292295, 292f,
293f, 294f
perineal wound breakdown with, 294295
radiation effects on, 294295
steps in, 291
urethral injury with, 293294
vaginal injury with, 294
Abdominal wall. See also Abdominal wall
reconstruction
hematoma of
laparoscopic gastric bypass and, 220221
laparoscopic surgery and, 200201
hemorrhage from, laparoscopic gastric
bypass and, 220221
hernia of, 76, 77f
laparoscopic gastric bypass and, 202
reconstruction for. See Abdominal wall
reconstruction, component
separation in
incisional hernia repairrelated loss of, 536
injury to
laparoscopic surgery and, 200201
percutaneous gastrostomy tube placement
and, 153
Abdominal wall reconstruction
component separation in, 545568, 546f
547f
adhesiolysis for, 557
adipocutaneous advancement aps for,
554, 555f557f, 567
AlloDerm for, 559, 559f
bowel injury with, 557
deep venous thrombosis with, 568
dehiscence with, 563, 565
DERMABOND in, 567
drain placement for, 567
evisceration with, 563, 565
external oblique fascia incision for, 559
560, 560f562f
failure of, 560567, 564f, 565f, 567f
ap ischemia with, 554, 555f557f
uid therapy in, 554
hernia recurrence after, 563, 565
hernia sac excision for, 554, 556557
hernia sac preservation for, 556557,
557f558f
iatrogenic enterotomy with, 551, 553
ileus after, 553554
indications for, 545, 548
infection and, 554, 557f, 567
liposuction garments after, 568
mesh excision for, 554
muscle ap advancement and
approximation for, 560567, 564f,
565f, 566f
obesity and, 548, 549f550f
ostomy and, 548, 550f551f, 552f553f
partial-thickness loss with, 567568
partition methods in, 562563, 564f
peritoneal cavity entry for, 551, 553554
pulmonary embolism with, 568
rectus abdominis denervation with, 560
recurrent hernia after, 563, 565
respiratory insufciency with, 566567
seroma with, 554, 567
skin ap bullae with, 567568
skin incision for, 548550, 549f551f,
552f553f
skin necrosis with, 548
Abdominal wall reconstruction (Continued)
Spigelian hernia with, 559560
split-thickness skin graft excision for, 551,
553554, 553f
staged, 545, 546f547f
steps in, 548
venous congestion with, 554
tensor fascia lata aps for, 560563, 564f,
565f
Abortion, spontaneous, 6263
Abscess
appendectomy and, 301302, 303305
arteriovenous access and, 639, 639f
intra-abdominal
epigastric hernia repair and, 527528
laparoscopic splenectomy and, 579
laparotomy and, 9294, 93f
umbilical hernia repair and, 527528
paravesical, inguinal hernia repair and, 507
subphrenic, 92, 93f
laparoscopic splenectomy and, 579
Absorbable mesh wrap, in splenorrhaphy,
791792, 793f
N-Acetyl cysteine, 36
Achalasia, 187
esophagomyotomy for. See
Esophagomyotomy
Adenoma
adrenal, 421
parathyroid, 410, 411, 411f
Adhesiolysis
in abdominal wall reconstruction, 557
in incisional hernia repair, 533, 538, 539f,
540f
intestinal, 7576, 75f, 76f
Adhesions
abdominal
damage control surgery and, 806
laparoscopic gastric bypass and, 202
laparotomy and, 7172, 7374, 74f
intestinal, 7576, 75f, 76f
Adrenal artery, injury to, 426427
Adrenal gland
biochemical evaluation of, 422423
computed tomography of, 421, 422, 422f,
423f
evaluation of, 421423, 422f, 423f
hepatectomy-related injury to, 332333
long limb variant of, 423f
metastasis of, 423f
pheochromocytoma of, 423
removal of. See Adrenalectomy
Adrenal insufciency, 43
Adrenal vein
identication of, 426, 427f, 431, 431f
injury to
adrenalectomy and, 426, 427f
pancreatectomy and, 376377
Adrenalectomy, 421432
anterior transperitoneal approach to, 423
biochemical evaluation before, 422423
imaging before, 421422, 422f, 423f
indications for, 421, 422f
laparoscopic transperitoneal approach to,
424, 425428
adrenal vein in, 426, 427f
 878 INDEX
Adrenalectomy (Continued)
arterial dissection for, 426427
bowel injury with, 426
diaphragm injury with, 427, 427f
dissection for, 426427
fractures with, 426
gastric injury with, 427
inferior vena cava dissection for, 426
kidney dissection for, 427
liver mobilization for, 426
nerve injury with, 425426
positioning for, 425426, 425f
solid organ injury with, 426, 428
steps in, 425, 425t
trocar insertion for, 426, 426f
trocar site closure for, 428
vascular injury with, 426, 427, 427f
Nelsons syndrome after, 423
open anterior approach to
abdominal entry for, 428
arterial dissection for, 430
colonic injury with, 428, 429
dissection for, 430
duodenal injury with, 428
hepatic exure injury with, 428
left, 428430
lymphatic injury with, 430
pancreatic injury with, 429
pancreatic mobilization for, 428430
right, 428, 429f
small bowel injury with, 428
splenic injury with, 429430
open posterior approach to, 424, 430431
arterial dissection for, 431, 431f
closure for, 431
incision for, 430
lumbar hernia with, 431, 431f
pleural injury with, 430
positioning for, 430
renal dissection for, 430431
renal hemorrhage with, 430431
renal vein injury with, 431
rib resection for, 430
steps in, 430
vascular injury with, 430
vena cava injury with, 431
open transperitoneal approach to, 424
partial, 431432, 432f
retroperitoneal posterior approach to, 424,
431432, 432f
thoracoabdominal approach to, 424
Afferent loop syndrome, after Billroth II
reconstruction, 230
Abrinogenemia, 40t
Aganglionosis. See Hirschsprungs disease
Air embolism
central vein catheterization and, 114
laparoscopic hepatectomy and, 365366
right hepatectomy and, 331332
trauma and, 762
Air-uid level, postlaparotomy, 94
Air leak, bronchial and vascular sleeve
lobectomy and, 689
Airway
compromise of, 51
edema of, tracheal resection and, 751
esophagectomy-related injury to, 730731,
731f
establishment of, before tracheal resection,
742
loss of
in anterior mediastinotomy, 666667
before tracheal resection, 742
metastable, 760761
in neck trauma, 810811, 810f
risk assessment for, 3334, 34f, 35f
Airway (Continued)
in thyroid surgery, 398, 398f, 404
in trauma, 757, 758f760f, 810811, 810f
unstable, 760761
visualization of, in rigid bronchoscopy,
659660
Alcohol dependence, 2930, 29b, 30f
CAGE questionnaire for, 30, 30b
Aldosterone, adenoma secretion of, 423
Allis clamps, for venous hemorrhage, 84, 85f
AlloDerm
in component separation procedure, 559,
559f
in damage control surgery, 807
in failed component separation procedure,
561562, 566f
Amnesia, inadequate, 51
Amnestic agents, 50t
Amputation, in melanoma, 499
Anal stulotomy, 315318
anesthesia for, 315
cut for, 317318, 317f
stula persistence with, 317318
Goodsalls rule for, 316, 316f
hydrogen peroxide injection for, 316, 316f
indications for, 315
opening identication for, 315316, 316f,
317f
sphincter assessment for, 316317, 317f
sphincter weakening with, 316317
steps in, 315
urinary retention with, 315
Anal sphincter
division of, 829, 829f
stulotomy-related weakening of, 316317
hemorrhoidectomy-related injury to, 308
309
Anal stenosis, hemorrhoidectomy and, 308,
309, 309f
Anal stricture, hemorrhoidectomy and, 311,
312
Analgesia, 2829, 28t, 29t, 50t
inadequate, 51
in chest tube insertion, 137138
in thoracic trauma, 776777
postoperative
narcotic, 2829, 29t
non-narcotic, 2829, 28t
Anastomosis
bleeding of
gastrectomy and, 229
laparoscopic gastric bypass and, 208
rectal resection and, 285, 285f
dehiscence of
colectomy and, 263
tracheal resection and, 746, 748750,
749f
granulation formation of, tracheal resection
and, 747748
leakage from
biliary resection and, 394395
colectomy and, 269270, 269f
enterectomy and, 237, 242243
esophagectomy and, 736737
gastrectomy and, 227229, 228b
gastric bypass and, 215216, 215f
Hirschsprungs disease repair and, 833
834
pancreaticojejunostomy and, 382
pyloroplasty and, 171172
rectal resection and, 283285
Roux-en-Y cystjejunostomy and, 384
tracheoesophageal stula repair and, 853
stricture of
enterectomy and, 241242, 243f, 244f
esophagectomy and, 738
Anastomosis (Continued)
gastrectomy and, 230231
rectal resection and, 285286
Anatomic Complications of General Surgery, 8
Anesthesia
in anal stulotomy, 315
in anterior mediastinotomy, 666667
in congenital diaphragmatic hernia repair,
857
in exible bronchoscopy, 661
in greater saphenous vein ablation, 645
in hemorrhoidectomy, 307308
local, 4950, 50t
in stereotactic image-guided breast
biopsy, 438439
in ultrasound image-guided breast biopsy,
443444
pitfalls in, 4964
block-specic, 5356, 53t, 54f, 55f, 56f,
57f
inpatient, 5664
aspiration and, 63
cardiovascular system, 5960
cardioverter-debrillatorrelated, 6061
medications and, 5658
nausea and vomiting and, 6364, 64b,
64t
neurologic system, 5859, 58b, 59t
pacemaker-related, 6061
pediatric, 6364
pregnancy-related, 6263
pulmonary system, 6162
outpatient, 4953, 50t
cardiovascular system, 52
hematologic system, 5253
neurologic system, 4951, 50t
respiratory system, 50t, 5152
in rigid bronchoscopy, 659
Aneurysm
abdominal aorta. See Abdominal aortic
aneurysm
pulmonary artery, catheter-related, 124
127, 125f, 126f
Angiography
in infrainguinal revascularization, 617618,
618f, 619f, 624, 625f
in neck injury, 813814, 814b
Angiolymphoid hyperplasia, of breast, 449
Angioplasty, 653654
arterial dissection with, 653
arterial perforation with, 653
embolization with, 653654
patch, in carotid endarterectomy, 592593,
593f
Angioscopy, in infrainguinal revascularization,
624
Ankle block, 53t, 5556, 57f
Ankle/brachial index, 613
Anoplasty, 829830
asymmetrical sphincter division with, 829
dehiscence after, 830
mucosal prolapse with, 830
perineal body reconstruction for, 830
rectal dissection for, 829
sphincter division for, 829, 829f
steps in, 829
stricture after, 830
urethral injury with, 829
vaginal injury with, 829
Anorectal malformations, 827832
classication of, 827, 828t
evaluation of, 827
incidence of, 827
repair of, 827832
anoplasty for, 829830, 829f
colostomy for, 830832, 831f, 832f

Anorectal malformations (Continued)
in female patient, 828829, 828f, 829f
in male patient, 828, 828f
posterior sagittal anorectoplasty for, 831
832
Anorectoplasty, sagittal, posterior, 831832,
832f
steps in, 831
urethral diverticulum with, 831
Anterior resection syndrome, 287. See also
Low anterior resection
Antiarrhythmia agents, prophylactic, in
pneumonectomy, 700
Antibiotics, preoperative, 37, 38t
in mastectomy, 476
Anticoagulation
in infrainguinal revascularization, 621622
preoperative assessment of, 39
in venous thrombosis, 41
Antiemetics, 6364, 64t
Antiplatelet agents, perioperative management
of, 39
Anus
congenital malformation of. See Anorectal
malformations
stula of. See Anal stulotomy
imperforate. See Anorectal malformations
resection of. See Abdominal perineal
resection
Anxiolysis, inadequate, 51
Anxiolytic agents, 50t
Aorta
aneurysm of. See Abdominal aortic
aneurysm
dissection of, in aortobifemoral bypass,
601602
injury to
laparoscopic Nissen fundoplication and,
182, 182f
trauma and, 774775
vagotomy and, 172
in neuroblastoma resection, 864865, 865f
surgery on, 597611. See also Abdominal
aortic aneurysm; Aortobifemoral bypass
clamping sequence for, 598
polytetrauoroethylene vs. Dacron grafts
for, 597598
transperitoneal vs. retroperitoneal, 598
599, 598f
Aortic arch, right-sided, 849850
Aortic stenosis, 5960
Aortobifemoral bypass, 599604
anastomoses for, 597, 598f
end-to-end, 597
end-to-side, 597, 598f
femoral, 602603
proximal, 602
bleeding with, 603
Bookwalter retractor for, 601, 601f
bowel injury with, 603
dissection for, 601602
duodenal injury with, 601
fecal stula with, 603
femoral artery exposure for, 600, 600f
femoral nerve injury with, 600
ank bulge with, 604
graft tunneling for, 602603, 602f
indications for, 599
inferior vena cava injury with, 602
left ank skin incision for, 600601
lymphatic leak with, 600
peritoneal cavity inspection for, 603604
peritoneal reection for, 601, 601f
peritoneal tear with, 600601
positioning for, 599, 599f
skin markings for, 599600, 599f
Aortobifemoral bypass (Continued)
small intestine obstruction with, 603604
splenic laceration with, 601
steps in, 599
suture line bleeding with, 602
ureteral division with, 603
venous injury with, 602603
Aortoenteric stula, abdominal aortic
aneurysm repair and, 609
Appendectomy, laparoscopic, 299305
abscess after, 304305
appendiceal stump leak with, 303304,
304f
bladder injury with, 300
colon injury with, 301302
dissection for, 301303, 301f, 302f
epigastric vessel injury with, 300
indications for, 299
mesenteric bleeding with, 303
mesenteric division for, 303, 303f
resection for, 303305
specimen pouch for, 301, 301f
staple line inspection for, 303, 303f
staple placement in, 303, 303f
steps in, 299
stump infection with, 304
trocar insertion for, 300301, 300f
ureteral injury with, 302303
wound infection with, 300301
Appendiceal artery, bleeding from, 303
Appendicitis, 299. See also Appendectomy
in children, 824
stump, 304
Argon beam coagulation
in splenorrhaphy, 791, 793f
in trisectionectomy, 347
Arrhythmias
bupivacaine and, 52
central vein catheterization and, 115
esophagectomy and, 735736
laparoscopic surgery and, 101, 199
pectus excavatum repair and, 847
pneumonectomy and, 699700
pulmonary artery catheterization and, 123
Arterial catheterization, 129134
axillary artery, 131
infection with, 131
paresthesias with, 131, 133f, 134
femoral artery, 131
bleeding with, 131, 132f
indications for, 129
pulmonary artery. See Pulmonary artery
catheterization
radial artery, 129131, 130f
infection with, 129130
ischemia with, 131
pseudoaneurysm with, 130, 130f
thrombosis with, 129
Arterial steal, arteriovenous access and, 637
638, 638f
Arteriography
in infrainguinal revascularization, 617618,
618f, 619f, 624, 625f
in neck injury, 813814, 814b
Arteriotomy
in carotid endarterectomy, 591
long, carotid endarterectomy and, 593
Arteriovenous stula
inferior vena cava lter placement and, 649
residual, after infrainguinal revascularization,
617618
Arteriovenous hemodialysis access, 631640,
632b
anastomosis for, 638639
arterial dissection for, 637638
arterial steal with, 637638, 638f
INDEX 879
Arteriovenous hemodialysis access (Continued)
brachialantecubital vein, 632, 634f
brachialbasilic vein, 631632, 633f
central venous stenosis in, 633, 634f, 635f
congestive heart failure with, 638639
early thrombosis with, 632634
graft maturation failure with, 636637
hemorrhage with, 639
imaging before, 631, 632b, 634, 636
indications for, 631
infection with, 639, 639f
ischemic monomelic neuropathy with, 638
late thrombosis with, 634635, 636f
posterior radial branchcephalic vein, 631,
632f
pseudoaneurysm with, 640, 640f
pulse examination for, 637638
seroma with, 639640, 640f
side branch ligation for, 637, 637f
venous exposure for, 632637
venous hypertension with, 635636
wound closure for, 639640
Artery of Ademkiewicz, in posterior
mediastinal mass resection, 721
Ascites
chylous, postvagotomy, 169
pancreatic, 388389
paracentesis for, 143146. See also
Paracentesis
refractory, umbilical hernia and, 528, 528f
Asphyxiating thoracic dystrophy, pectus
excavatum repair and, 842
Aspiration
esophagectomy and, 736
during induction, 63
Associative phase, of Fitts and Posner skill
acquisition model, 6, 6f
Asthma, perioperative management of, 61
Atelectasis
bronchial and vascular sleeve lobectomy
and, 689690
esophagectomy and, 733734
Atheroembolism, in abdominal aortic
aneurysm repair, 607
Atrial brillation, 3233
Atrioventricular dissociation, laparoscopic
surgery and, 101
Atypical intraductal hyperplasia, of breast,
448449
Autonomous phase, of Fitts and Posner skill
acquisition model, 6, 6f
Aviation training, 1112
Axillary artery
cannulation of, 131, 133f, 134
dissection-related injury to, 467
Axillary dissection, 465468, 466f, 467f
drain placement for, 468
hemostasis for, 467468
incision for, 465466
indications for, 465
lymphedema after, 467
nerve injury with, 466467, 466f, 467f
steps in, 465
technique of, 466467, 466f
vascular injury with, 467
Axillary vein, dissection-related injury to, 467
Azygos vein, resection-related injury to, 724,
724f
B
Balloon tamponade, in neck injuryrelated
bleeding, 811, 811f
Bancroft closure, in gastrectomy, 225, 226f
Bariatric surgery. See Gastric bypass,
laparoscopic
 880 INDEX
Benign papillary lesion, of breast, 446447,
447f
Bicarbonate, with contrast agents, 36
Bile duct. See also Biliary tract
common
in biliary resection and reconstruction,
394
cholecystectomy-related injury to, 320
321, 321f, 321t, 322b
identication of, 783
extrahepatic. See also Biliary tract
anatomy of, 392, 392f
blood supply to, 391, 392f
resection-related stricture of, 394
trisectionectomy-related ischemia of, 349
Bile leak
cholecystectomy and, 323, 324, 326327
laparoscopic hepatectomy and, 365
right hepatectomy and, 337338
trisectionectomy and, 352354
Bile reux gastritis, 231232
Biliary tract
damage control surgery for, 802
resection and reconstruction of, 391396
anastomosis for, 394395
anastomotic leak with, 394395
bile duct isolation for, 391394, 392f,
393f
biliary stricture with, 394
common hepatic artery injury with, 392
distal stump leak with, 394
excision for, 394, 394f
hepatic artery injury with, 392393
hepatic duct leak with, 395
incision for, 391
indications for, 391
peribiliary vessel bleeding with, 391392
portal vein injury with, 393394
steps in, 391
Biliopancreatic limb, in laparoscopic gastric
bypass, 205
Billroth gastrojejunostomy, 227229, 227t,
228f, 229f
cancer after, 233
Biopsy
breast. See Breast biopsy
chest wall, 706707
parathyroid gland, 412
sentinel lymph node. See Sentinel lymph
node biopsy
soft tissue sarcoma, 490491
supraclavicular lymph node, 583584
Bladder
dysfunction of, after low anterior resection,
282283
injury to
inguinal hernia repair and, 517
laparotomy and, 8284
paracentesis and, 144, 144f
rectal resection and, 274275, 275f
trocar placement and, 300
mesh migration into, in laparoscopic
incisional hernia repair, 542
Bleeding
abdominal wall, gastric bypass and, 220
221
adrenalectomy and, 426427, 427f
anastomotic
gastrectomy and, 229
laparoscopic gastric bypass and, 208
rectal resection and, 285, 285f
anterior gastrotomy and, 383384
anterior mediastinotomy and, 667
aortobifemoral bypass and, 602, 603
appendectomy and, 303
arteriovenous access and, 639
Bleeding (Continued)
bronchial and vascular sleeve lobectomy
and, 688
bronchoscopy and, 661
carotid endarterectomy and, 593
cholecystectomy and, 321322, 324, 326
colectomy and, 261262
cystgastrostomy and, 383384
damage control surgery and, 802803
endovascular intervention and, 651652
enterectomy and, 240
esophagectomy and, 728730, 729f
esophagomyotomy with Dor fundoplication
and, 194
femoral artery cannulation and, 131, 132f
gastric bypass and, 200201, 203, 204
205, 208209, 211, 213, 216
hemorrhoidectomy and, 308, 313
hepatectomy and, 330, 336337, 361,
364365
incisional hernia repair and, 538
infrainguinal revascularization and, 621,
625626, 625f
inguinal hernia repair and, 502503, 517,
518
isolated limb perfusion of melphalan and,
499
laparoscopic surgery and, 100
mastectomy and, 479
mediastinoscopy and, 664665
mesenteric, laparoscopic gastric bypass and,
204205, 208209, 213, 219
neck injury and, 811, 811f
open gastrostomy and, 149
pancreatectomy and, 375376, 377
pancreatic dbridement and, 385, 387
pancreaticoduodenectomy and, 368, 369
370, 372
paracentesis and, 145
pelvic trauma and, 767768
pulmonary artery, 124127, 125f, 126f
rectal resection and, 275277, 276f, 277f,
279, 281282, 282f, 285, 285f
right hepatectomy and, 330, 336337
risk assessment for, 39, 40t
Roux-en-Y cystjejunostomy and, 384
splenectomy and, 574, 575, 576578
stereotactic image-guided breast biopsy and,
441
trauma and, 762763, 769770, 770f
trisectionectomy and, 349352
ultrasound image-guided breast biopsy and,
445446, 445f
VATS lobectomy and, 681682
venous, laparotomy and, 8485, 85f
-Blockers
in atrial brillation prevention, 33
in myocardial infarction prevention, 3132,
32b, 57
Blood pressure, trauma-related, 763
Blood transfusion
in total mastectomy, 479
in trisectionectomy, 350
Bogota Bag, 90, 91f
Bookwalter retractor, in aortobifemoral
bypass, 601
Bougie insertion, for laparoscopic Nissen
fundoplication, 180181, 181f
Brachial plexus injury
adrenalectomy and, 425426
axillary dissection and, 467
Brachiocephalic vein, thymectomy-related
injury to, 718719
Bracing, 1920, 20f, 99, 99f
Bradyarrhythmias, laparoscopic surgery and,
101
Bradycardia, laparoscopic surgery and, 199
Brain, trauma to. See Traumatic brain injury
BRCA, 45t
Breast
angiolymphoid hyperplasia of, 449
atypical intraductal hyperplasia of, 448449
benign papillary lesion of, 446447, 447f
biopsy of. See Breast biopsy
calcications of, 450
cyst of, 442
ductal carcinoma in situ of, 449
at epithelial atypia of, 449450, 450f
radial scar of, 450451, 451f
removal of. See Mastectomy
Breast biopsy
image-guided, 433451
indications for, 433434
infection after, 475476
pathologic pitfalls with, 446451
angiolymphoid hyperplasia/lobular
carcinoma in situ and, 449
artifacts and, 447
atypical intraductal hyperplasia and,
448449
benign papillary lesion and, 446447,
447f
calcications and, 450
ductal carcinoma in situ and, 449
edge artifact and, 447
estrogen receptor immunostain and,
448
at epithelial atypia and, 449450,
450f
HER-2 assessment and, 447448, 448f
lobular carcinoma in situ and, 449
radial scar and, 450451, 451f
thermal injury and, 447
tissue crush and, 447
tissue retraction and, 447
underxation and, 448
stereotactic, 434442
anesthetic preparation for, 438439
bleeding with, 441
clip migration with, 441442
compression thickness in, 438
device insertion for, 439
device misselection with, 440441
ne-needle aspiration needle for, 440
inappropriate mammogram lesion with,
434
lesion depth with, 436437, 437f, 438f
lesion mislocation with, 435
lesion mispositioning with, 436
lesion misvisualization with, 435436
lesion targeting for, 438
lesion window positioning for, 436,
437f
mammogram evaluation for, 434436
mistaken approach with, 435
negative stroke margin with, 436437,
437f, 438, 438f, 439
patient characteristics in, 434435
patient positioning for, 436, 436f
postprocedure images for, 441442
sample adequacy for, 440441
specimen radiograph for, 442
steps in, 434
stroke margin in, 436437, 437f, 438,
438f, 439
targeting errors with, 439440, 440f
Tru-Cut device for, 440441
VAB device for, 440441
ultrasound, 442446
alignment failure with, 444, 445f
anesthesia for, 443444
bleeding with, 445446, 445f

Breast biopsy (Continued)
conrmation scans for, 444, 445f
cystic lesion on, 442
device insertion for, 444
device selection for, 445
dressing for, 445446
focal zone for, 443, 443f
hematoma with, 445446, 445f
hemothorax with, 444
image optimization for, 443, 443f
lesion sampling for, 445
mispositioning with, 442443
pneumothorax with, 444
poor image optimization with, 443
position for, 442443
steps in, 442
open, 455458
cosmetic outcomes of, 457458
hematoma with, 458
incision placement for, 457458
indications for, 455
lesion marking for, 456
lesion mislocalization with, 456457
localization for, 456457, 457f, 458f
radiography for, 458
resection for, 458
steps in, 455
Breathing. See also Airway
evaluation of, 761762
Bronchial and vascular sleeve lobectomy, 685
691
air leaks with, 689
anastomotic torsion or kinking with, 689
arterial thrombosis with, 690691
atelectasis with, 689690
bronchial anastomosis for, 687f, 689690,
690f
bronchoscopy for, 687688
complications of, 691
double-lumen tube placement for, 688,
688f
ap devascularization with, 690
hilar dissection for, 688
historical perspective on, 685
hypoxia with, 688
indications for, 685, 686f
lymphadenectomy and, 691
pedicled aps for, 690
pulmonary artery reconstruction for, 690
691, 690f, 691f
steps in, 685, 687, 687f
vascular injury with, 688
Bronchocutaneous stula, chest tube insertion
and, 138139
Bronchopleural stula
chest tube insertion and, 138139
pneumonectomy and, 698699, 698f, 699f
Bronchoscopy, 657662
in bronchial and vascular sleeve lobectomy,
687688
exible, 660662, 660f
anesthesia for, 661
complications of, 661662
indications for, 660, 661f
postoperative, 660
steps in, 657658
rigid, 658660, 658f
airway nonvisualization with, 659660
complications of, 661662
inadequate surgeon-anesthesiologist
cooperation with, 659
inappropriate patient for, 658659
indications for, 658, 658f
noninsertion with, 659
patient recovery from, 660
positioning for, 659
Bronchoscopy (Continued)
steps in, 657658
for tracheal resection, 741742, 742f
Bupivacaine, 50t
arrhythmia with, 52
Burn injury, saphenous vein ablation and, 646
C Catell and Braasch maneuver, 67, 69f
CAGE questionnaire, 30, 30b
Calcications, breast, 450
Calcium gluconate, in hypoparathyroidism,
400401
Calcium supplements, in hypoparathyroidism,
400401
Cancer
after Billroth II reconstruction, 233
breast. See Breast biopsy; Mastectomy
lung, 671. See also Bronchial and vascular
sleeve lobectomy; Pneumonectomy;
Video-assisted thoracic surgery (VATS)
lobectomy
chest wall resection for, 709712, 710f,
711f
supraclavicular lymph node biopsy in,
583584
parathyroid gland, 419
screening for, 44t45t, 45
Capnothorax, laparoscopic surgery and, 101
102
Carcinoma, ileostomy, 254
Cardiac herniation, pneumonectomy and,
695696, 696f
Cardiac output, laparoscopic surgery and, 101
Cardiac tamponade
central vein catheterization and, 115116,
117f
laparoscopic Nissen fundoplication and, 184
Cardiovascular disease, risk assessment for,
3032, 31t, 32b, 32t
Cardioversion, 32
Cardioverter-debrillator, perioperative
management of, 6061
Carotid artery
high bifurcation of, 592
node biopsyrelated injury to, 583
stent for, 593594
Carotid artery disease, 2728, 28f. See also
Carotid endarterectomy
Carotid body, 588589, 588f
Carotid endarterectomy, 2728, 28f, 585594
arterial control for, 590591, 590f
arteriotomy for, 591
baroreceptor perturbation with, 588589
bleeding with, 593
carotid kink in, 587, 587f
closure for, 593
cranial nerve injury with, 589
cutaneous nerve injury with, 590
difcult endpoint in, 592
dissection and exposure for, 588590, 588f,
589f
fundamental principles of, 586
high carotid bifurcation in, 592
hypoglossal nerve injury with, 589, 589f
improper positioning with, 586
incision for, 587588, 587f
indications for, 586
intracranial circulation evaluation for, 591,
591f
limited exposure with, 587588
long arteriotomy with, 593
marginal mandibular nerve injury with,
589590
patch angioplasty for, 592593, 593f
positioning for, 586
INDEX 881
Carotid endarterectomy (Continued)
results of, 585
shunt for, 591, 591f
steps in, 586
stroke with, 590591
suture line bleeding with, 593
technique of, 592, 592f
vagus nerve in, 588, 588f, 589
Catheter(s)
arterial, 129134. See also Arterial
catheterization
infection of, 129130, 131
thrombosis with, 129
central vein. See also Central vein
catheterization
infection of, 116
thrombosis with, 116117
intravenous, in trauma, 765
pulmonary artery, 122, 122f. See also
Pulmonary artery catheterization
coiling/knotting of, 123124, 124f
urinary, in trauma, 766
Celiac artery
stenosis of, pancreaticoduodenectomy and,
371
thrombosis of laparoscopic Nissen
fundoplication and, 184
Cellulitis
arteriovenous access and, 639
epigastric hernia repair and, 527
umbilical hernia repair and, 527
Central vein catheterization, 107117
air embolism with, 114
in anticoagulated patient, 112
arrhythmia with, 115
arterial puncture with, 112113, 113f
body mass index and, 112
cachexia and, 112
cardiac perforation with, 115116, 116f
checklist for, 108109, 108f
coagulation prole before, 112
femoral vein, 110, 111f
guidewire loss with, 115, 115f
indications for, 107
infection with, 116
internal jugular vein, 109, 111f
patient characteristics in, 111112, 111f
pneumothorax with, 113114, 114f
Seldinger technique for, 110
setup for, 108109, 108f
steps in, 107108
subclavian vein, 109110, 111f, 112
thoracic duct injury with, 114115
ultrasound guidance for, 110111
venous thrombosis with, 116117
Central venous pressure, in right hepatectomy,
337
Central venous stenosis, in arteriovenous
access procedures, 633635, 634f, 635f
Cerebral perfusion pressure, 787, 787b, 788f
Cerebrospinal uid leak, posterior mediastinal
mass resection and, 722
Cerebrovascular injury, blunt, 768769, 769b
Cervical collar, in neck injury, 811812
Cervical spine injury, intubation and, 58
Chest tube insertion, 135142
analgesia for, 137138
aseptic technique for, 136137
after congenital diaphragmatic hernia repair,
860
diaphragmatic perforation with, 135136,
136f, 137f
effusion with, 141
empyema with, 136137
ngersweep for, 138139, 139f
 882 INDEX
Chest tube insertion (Continued)
inadequate analgesia with, 137
incision for, 138
indications for, 135
insertion site selection for, 135136
intercostal nerve injury with, 138, 138f
intercostal vessel injury with, 138
intra-abdominal placement with, 139, 140f
lung apex placement with, 140
lung laceration with, 138139
mediastinum placement with, 140141
nonfunctional drain with, 141
patient positioning for, 135
pneumothorax with, 141
reexpansion pulmonary edema with, 141
142
steps in, 135
subcutaneous tissue placement with, 140
tube placement for, 140141
tube suturing for, 141
unnecessary, in trauma, 761, 762
wound site infection with, 136
Chest wall
infection of, 714715
Pancoasts tumor of, 712714, 713f
pectus excavatum of. See Pectus excavatum
resection of. See Chest wall resection
Chest wall resection, 708715
biopsy before, 706707
dissection for, 710711, 711f
dorsal nerve root injury with, 711712
historical perspective on, 708709
imaging before, 710, 711f
incomplete, 710
indications for, 708
for infection, 714715
intercostal artery bleeding with, 712
for lung cancer, 709712, 710f, 711f
margins for, 707708, 707f, 710
for Pancoasts tumor, 712714, 713f
pleural space entry for, 711
poor planning for, 705
preparation for, 708
for primary tumor, 706709, 707f, 708f,
709f
reconstruction after, 708709, 708f, 709f
skin incision misplacement with, 711
spinal consultation for, 711
thoracotomy misplacement with, 711
Child-Pugh classication, 35, 35t
Children
anorectal malformations in, 827832, 828f,
828t, 829f, 832f
appendicitis in, 824
bowel obstruction in, 823825, 823f, 824f
diaphragmatic hernia in, 857860, 858f,
859f
Hirschsprungs disease in, 832835, 832f,
834f, 835f
hypertrophic pyloric stenosis in, 871874,
873f
inguinal hernia in, 867869, 868f
intestinal malrotation in, 819823, 820f,
821f, 822f
intubation in, 63
neuroblastoma in, 863865, 864f, 865f
pectus excavatum in, 839847. See also
Pectus excavatum
tracheoesophageal atresia/stula, 849855.
See also Tracheoesophageal stula repair
umbilical hernia in, 869, 869f
Wilms tumor in, 861863, 862f, 864
Chin stitch, in tracheal resection, 750, 750f
Chloroprocaine, 50t
Cholangiography, in trisectionectomy, 353,
354
Cholecystectomy, 319327
laparoscopic, 320324
bile duct injury with, 319, 320321,
321f, 321t, 322b
bile leak with, 323
cystic artery in, 322, 322f
cystic duct in, 322, 322f
dissection for, 323
gallbladder perforation with, 323
hemobilia with, 323
hepatic artery injury with, 321322, 322f
indications for, 320
liver injury with, 323
Rouvieres sulcus in, 321, 321f
steps in, 320
trocar insertion for, 320, 320f
viscus injury with, 323324
open, 324325
bleeding with, 324
closure for, 325
cystic artery ligation for, 324325
cystic duct ligation for, 324325
incisional hernia with, 325
indications for, 324
infection with, 325
liver resection and, 325327, 325f, 326f
bile leak with, 326327
bleeding with, 326
nodal resection for, 327
portal vein injury with, 327
steps in, 324
Chronic obstructive pulmonary disease, 33
34, 35f
Chunking, 56
Chvosteks sign, 400
Chylothorax
congenital diaphragmatic hernia repair and,
860
esophagectomy and, 733, 733f, 737, 737b
pneumonectomy and, 693694
posterior mediastinal mass resection and,
723
VATS lobectomy and, 682
Chylous ascites, postvagotomy, 169
Chylous stula
adrenalectomy and, 430
mastectomy and, 485
supraclavicular lymph node biopsy and,
584
Cigarette smoking
history of, 3738
preoperative cessation of, 38
Cirrhosis, laparoscopic gastric bypass and,
201202
Cisterna chyli, in vagotomy, 169
Clamping
in abdominal aortic aneurysm repair, 598,
605607, 605f, 606f, 607f, 608f
in aortic surgery, 598
blind, in trauma, 762763
in trisectionectomy, 351
Claudication, revascularization for. See
Infrainguinal revascularization
Claw sign, 864, 864f
Coagulation factors, deciency of, 39, 40t
Cognitive phase, of Fitts and Posner skill
acquisition model, 6, 6f
Cognitive remodeling, 7, 7f
Colectomy
left, 265270
anastomosis for, 269270, 269f
anastomotic leak with, 269270
bowel injury with, 270
indications for, 265
laparoscopic, 265266
open, 265, 270
Colectomy (Continued)
peritoneal incision and sigmoid
mobilization for, 266268, 266f,
267f, 268f
proximal colon division for, 268269
splenic injury with, 268269
steps in, 265266
ureter injury with, 167f, 266267
vascular injury with, 267268
right, 257264
anastomosis for, 262, 263f, 264f
cecum mobilization for, 259260, 260f
deep vein thrombosis with, 263
dissection for, 259260, 259f, 260f
duodenal injury with, 261
exploration for, 258259
hepatic exure mobilization for, 260
261, 261f
indications for, 257
small bowel injury with, 259260
steps for, 257258
trocar placement for, 258
ureteral injury with, 259260
vascular control for, 261262, 262f
wound infection with, 263
Colic artery
ligation of, in colectomy, 269, 269f
middle, ligation of, 387
Colic vein, middle, pancreatectomy and, 375
376
Colitis
ileostomy and, 254
ischemic, ruptured abdominal aortic
aneurysm and, 611
Colon
injury to
adrenalectomy and, 426, 428, 429
aortobifemoral bypass and, 603
appendectomy and, 301302
cholecystectomy and, 323324
component separation procedure and,
557
inguinal hernia repair and, 506
laparoscopic gastric bypass and, 213
laparoscopic incisional hernia repair and,
539
laparoscopic splenectomy and, 573574
laparoscopic surgery and, 97100, 98f
laparotomy and, 7475, 75f, 76f
open gastrostomy tube placement and,
148
paracentesis and, 144, 144f
percutaneous gastrostomy tube placement
and, 151152, 152f
stoma dissection and, 7778, 78f
ventral hernia repair and, 76, 77f
obstruction of, incisional hernia and, 534
535
splenic exure of, retraction of, 8081, 82f
Color ow Doppler, in neck injury, 814, 814b
Colostomy
abdominal perineal resection and, 295297,
295f, 296f
leakage with, 297
obesity and, 197f, 297
parastomal hernia with, 297
stomal necrosis with, 295296
stomal stenosis with, 297, 297f
component separation procedure and, 548,
552f553f
pediatric, 830831
colon division for, 830
ischemia with, 830831
mucous stula for, 830831
prolapse with, 830
rectal dilatation with, 831

Colostomy (Continued)
steps in, 830
urinary tract contamination with, 831
Common femoral vein, saphenous vein
ablationrelated injury to, 645646
Common iliac vein, aortic aneurysm repair
related injury to, 607609
Common peroneal nerve, infrainguinal
revascularizationrelated injury to, 616
Communication, surgeon-patient, 2324
Compartment syndrome
abdominal, 803, 805806
laparotomy and, 8991, 90f, 91f
with congenital diaphragmatic hernia repair,
860
Competency, 7
Complications in Surgery, 8
Complications in Surgery and Trauma, 8
Component separation, in abdominal wall
reconstruction. See Abdominal wall
reconstruction, component separation in
Computed tomography
of accessory spleen, 422f
in adrenal gland evaluation, 421, 422, 422f,
423f
in gastric fundus mass, 422f
in neck injury, 814815
in pancreatic injury, 779
in pelvic trauma, 768
in soft tissue sarcoma, 491492, 491f
in splenic injury, 794, 795797, 796f
in traumatic brain injury, 786, 786f
in varix, 422f
Computed tomography angiography, in neck
injury, 815
Congestive heart failure, arteriovenous access
and, 638639
Contiguity, in technical skill learning, 13
Continuous positive airway pressure, in
obstructive sleep apnea, 6162
Contrast media
nephrotoxicity of, 36
for pelvic computed tomography, 768
toxicity of, endovascular intervention and,
651
Coopers ligament, in laparoscopic inguinal
hernia repair, 517
Coronary artery bypass graft, carotid
endarterectomy and, 28
Corticosteroids
weaning from, 750
wound healing impairment and, 43
Cortisol, tumor secretion of, 423
Costochondral junction, pectus excavatum
repairrelated injury to, 840841
Coumadin, perioperative management of, 39,
41f
Cowden disease, 44t
Cranial nerve, carotid endarterectomyrelated
injury to, 589
Cremaster entrapment, inguinal hernia repair
and, 868
Cricothyroidotomy, in neck injury, 810811
Cricothyrotomy, 757, 758f760f
Cryopreservation, of parathyroid gland, 418
Cushings syndrome, fracture in, 426
Cutaneous nerve, carotid endarterectomy
related injury to, 590
Cyst
breast, 442
pancreatic. See Pancreatic cyst
Cystgastrostomy, 383384
Cystic artery
in biliary resection and reconstruction, 394,
394f
in cholecystectomy, 322, 322f
Cystic duct
in biliary resection and reconstruction, 394,
394f
in cholecystectomy, 322, 322f
Cystjejunostomy, Roux-en-Y, 384
D adrenalectomy and, 427, 427f
Dacron graft, vs. polytetrauoroethylene graft,
597598
Damage control surgery, 799806
access for, 800801
adhesions and, 806
AlloDerm for, 807
biliary tract injury with, 802
biologic material for, 807
bleeding with, 802803
closure for, 803, 805806
compartment syndrome with, 803, 805
806
contamination control for, 802
DC 0 steps for, 799800
DC 1 steps for, 800803
DC II steps for, 803805
DC III steps for, 805806
early implementation of, 799800
edema with, 805
enteroatmospheric stula with, 806
enterocutaneous stula with, 807
falciform ligament division for, 801
foreign body retention with, 805806
herniation after, 807
high transfusion requirement with, 804
hypotension with, 801
iatrogenic injury with, 801
indications for, 799
inspection for, 801802
packing for, 802803
pancreatic injury with, 802
prosthesis for, 806807
retroperitoneal hematoma with, 801802
self-retraining retractor placement for, 801
shunting in, 801802
solid organ injury with, 802
temporary closure for, 803
undetected injuries with, 804
ureteral injury with, 802
Dantrolene, in malignant hyperthermia, 59
Dbridement
mesentery, in colectomy, 269, 269f
in pancreatic necrosis, 386, 387388
Deep circumex iliac vein, aortobifemoral
bypassrelated injury to, 602603
Deep peroneal nerve, infrainguinal
revascularizationrelated injury to, 616
Deep venous thrombosis, 39, 4142, 42t
colectomy and, 263
component separation procedure and, 568
inferior vena cava lter placement in, 648
649, 648f
infrainguinal revascularization and, 628
laparoscopic surgery and, 103
saphenous vein ablation and, 646647
subfascial endoscopic perforator surgery
and, 647648
Delayed gastric emptying
gastrectomy and, 232233
left hepatectomy and, 342
pancreaticoduodenectomy and, 371372
Deliberate practice, 67
Delirium tremens, 2930
DERMABOND, in component separation
procedure, 567
Deserosilization, incisional hernia repair and,
533
Dexamethasone, 6364, 64t
INDEX 883
Diabetes insipidus, in traumatic brain injury,
789
Diabetes mellitus
pancreatic dbridement and, 387388
perioperative management of, 4243,
43b
Diaphragm, injury to
chest tube insertion and, 136137, 136f,
137f
right hepatectomy and, 332, 332f
splenectomy and, 574575
thoracic trauma and, 776, 776f
Diazepam, 50t
Diuretics, in esophagectomy, 734
Diverticulum, urethral, 831
Documentation
alteration of, 2526
completeness of, 25
family history, 4345, 44t45t
for informed consent, 24
review of, 26
Dog-ear deformity, in total mastectomy, 481,
481f
Double-lumen tube, in bronchial and vascular
sleeve lobectomy, 688, 688f
Double-stapling technique, in laparoscopic
gastric bypass, 207, 207f
Drain
in abdominal wall reconstruction, 567
in axillary dissection, 468
in mastectomy, 478
in tracheal resection, 743, 743f
Droperidol, 6364, 64t
Drugs
intoxication with, vs. mental status changes,
764
nephrotoxic, 36, 36b
preoperative, 5658
Dumping syndrome, 232
Duodenal injury
adrenalectomy and, 428
aortobifemoral bypass and, 601
cholecystectomy and, 323324
colectomy and, 261
management of, 779784
bile duct identication for, 783
delayed, 780
diagnosis in, 779780
exposure for, 780782, 780f, 781f
hemodynamic instability with, 782
inadequate pyloric exclusion with, 784
missed injury with, 781
principles of, 783784
replaced right hepatic injury with, 781
782
stabilization in, 779780
steps in, 779
right hepatectomy and, 332, 332f
Duodenal stump, blow-out of, in gastrectomy,
225
Duodenal ulcer
Helicobacter pylori infection and, 163164
perforation of
enlargement of, 160
after Graham patch repair, 164, 164b
nonoperative treatment of, 159, 160b
operative treatment of. See Graham patch
repair
sealed, 159, 160
pyloroplasty for. See Pyloroplasty
vagotomy for. See Vagotomy
Duodenum
injury to. See Duodenal injury
stenosis of, Graham patch repair and, 160
161
 884 INDEX
Duodenum (Continued)
transection of, for gastrectomy, 224226,
225f
ulcer of. See Duodenal ulcer
Dysphagia
laparoscopic esophagomyotomy and, 192
194
laparoscopic Nissen fundoplication and,
182183
vagotomy and, 169
Dyspnea, pneumonectomy and, 701
E ileus after, 245
Edema
airway, tracheal resection and, 751
anastomotic, laparoscopic gastric bypass
and, 208
damage control surgery closure and, 805
pulmonary
chest tube insertion and, 141142
pneumonectomy and, 700701, 700f
Efferent loop syndrome, 230
Electrolyte imbalance, paracentesis and, 145
146
Embolism
air
central vein catheterization and, 114
laparoscopic hepatectomy and, 363
trauma and, 762
gas
laparoscopic gastric bypass and, 198199
laparoscopic surgery and, 102
pulmonary artery, pneumonectomy and,
696698
pulmonary artery catheter, 127
tumor, pneumonectomy and, 696, 697f
Embolization
endovascular intervention and, 653654
plaque, infrainguinal revascularization and,
622
Emphysema, subcutaneous, laparoscopic
gastric bypass and, 199200
Empyema
chest tube insertion and, 136137
pneumonectomy and, 698699, 698f, 699f
Endarterectomy, carotid. See Carotid
endarterectomy
Endoscopic retrograde
cholangiopancreatography, in
trisectionectomy-related bile leak, 353
Endoscopy, in percutaneous gastrostomy tube
placement, 151, 152, 152f, 153, 153f,
154
Endovascular therapy, 651655
abdominal aortic aneurysm treatment with,
654655, 654f, 655f
access failure with, 654
device fatigue with, 654
endoleaks with, 654655, 654f, 655f
access site for, 651653, 652f
access site thrombosis with, 653
angioplasty for, 653654
arterial dissection with, 653
arterial perforation with, 653
contrast toxicity with, 651
embolization with, 653654
high arterial puncture with, 651652, 652f
indications for, 651
low arterial puncture with, 652
poorly angled puncture with, 652653
stenting for, 653654
steps in, 651
Enterectomy, 237245
anastomosis for, 238244
failure of, 237, 241243
Enterectomy (Continued)
leak from, 237, 242243
misalignment prevention in, 240, 241
patency check of, 242, 244f
staple line for, 240, 242f
stricture prevention in, 241242, 243f,
244f
sutures for, 240, 241f
technique of, 240241, 241f, 242f
bleeding with, 240
bowel obstruction after, 245
feeding after, 245
hematoma with, 240
incision for, 237238
closure of, 244
indications for, 237
infection with, 239, 239f
ischemia identication during, 238
lesion identication during, 238, 238f
ligation imprecision in, 240
mesenteric defect for, 239, 239f
closure of, 243244, 244f
missed lesions during, 238
nutritional deciency after, 245
short bowel syndrome after, 244245
stapler malfunction in, 239240
steps in, 237
transection sites for, 238
Enteroatmospheric stula, damage control
surgery and, 806
Enterocolitis, Hirschsprungs disease repair
and, 834
Enterocutaneous stula
damage control surgery and, 807
epigastric hernia repair and, 527528
incisional hernia repair and, 533, 535f, 536,
540
inguinal hernia repair and, 504
laparotomy and, 9294, 94f
umbilical hernia repair and, 527528
Enteroenterostomy
in laparoscopic gastric bypass, 205208
stenosis of, in laparoscopic gastric bypass,
207208
Enterotomy
component separation and, 551, 553
incisional hernia repair and, 533, 538
Ephedrine, 6364, 64t
Epigastric artery, injury to
appendectomy and, 300
cholecystectomy and, 324
jejunostomy and, 156157
laparoscopic inguinal hernia repair and,
518
right hepatectomy and, 330
Epigastric hernia. See Hernia, epigastric
Epigastric vein, inguinal hernia repairrelated
injury to, 518
Epinephrine, end-organ ischemia with, 52
Epithelial atypia, of breast, 449450, 450f
Equipment familiarization, in technical skills
instruction, 1617
Ericsson, K.A., 67
Error, 19. See also Technical skills instruction
analytical response to, 4
deection of, 4
fear of, 23, 4
gifted response to, 5
heuristics and, 34
knowledge-based, 3
morbidity and mortality conference for, 2,
45
observational detection of, 8
passive acceptance of, 4
rate of, 12
Error (Continued)
residents response to, 4
response to, 45
rule-based, 3
skill-based, 3
surgeons response to, 2426
Error training, 79, 7f
Esophageal atresia, 849855
diagnosis of, 849
repair of
end-to-end anastomosis for, 853854,
853f
esophageal injury with, 851852
esophageal leak with, 853
esophageal stenosis with, 853854, 854f
stula division for, 850851, 850f
GERD with, 854855
indications for, 849
long gap atresia and, 852853, 852f
long thoracic nerve injury with, 850
misligation with, 850851, 851f
missed upper pouch stula with, 850
posterolateral thoracotomy for, 849850
proximal and distal pouch dissection for,
851853
right-sided aortic arch and, 849850
steps in, 849
tracheal injury with, 851852
Esophagectomy, 727739
abdominal phase for, 728
airway injury with, 730731, 731f
anastomotic leak after, 736737
anastomotic stricture after, 738
arrhythmias after, 735736
aspiration after, 736
bleeding with, 728730, 729f, 730f
cervical phase for, 728
chyle leak with, 733, 733f, 737, 737b
complications of, 728b
conduit ischemia after, 735
diaphragmatic hernia after, 738739
gastric conduit for, 731732, 732f
hoarseness after, 734735
incisions for, 727
indications for, 727
paraesophageal hernia after, 738739
phases of, 728
pneumonia after, 736
recurrent laryngeal nerve injury with, 734
735
replacement conduit complications with,
731733, 732f
respiratory complications after, 733734
splenic injury with, 730
steps in, 727, 728b
transhiatal phase for, 728, 730, 730f
wound infection after, 737
Esophagography, in neck injury, 815
Esophagomyotomy, laparoscopic, 187194
anterior vagal nerve injury with, 194
bleeding with, 194
dissection for, 189, 189f
Dor fundoplication with, 193194, 193f
electrocautery in, 190
endoscope placement for, 188, 188f
esophageal perforation with, 190
gastric perforation with, 190
gastric vessel ligation for, 189
gastroesophageal reux/dysphagia after,
192194
incomplete myotomy with, 190192, 191f,
192f, 193f
indications for, 187188
mediastinal sepsis with, 190
mucosal injury with, 190, 190f, 192f
myotomy for, 190193, 191f, 192f, 193f

Esophagomyotomy, laparoscopic (Continued)
paraesophageal hernia with, 189, 189f
splenic injury with, 194
steps in, 188
trocar insertion for, 189
Esophagopleural stula, pneumonectomy and,
695
Esophagoscopy, 662663, 662f
in neck injury, 815
Esophagus
atresia of. See Esophageal atresia
excision of. See Esophagectomy
injury to
laparoscopic Nissen fundoplication and,
176177, 178f
laparotomy and, 8182, 83f
left hepatectomy and, 339340, 340f
mediastinal mass resection and, 723
thyroid surgery and, 403
tracheal resection and, 745, 745f
tracheoesophageal stula repair and, 851
852
VATS lobectomy and, 674
perforation of
laparoscopic esophagomyotomy with Dor
fundoplication and, 190, 190f
laparoscopic Nissen fundoplication and,
180181, 181f
vagotomy and, 168169, 168f
stenosis of, esophageal atresia repair and,
853854, 854f
in VATS lobectomy, 674, 674f
Estrogen receptor immunostain, on breast
biopsy, 448
Etilefrine chlorhydrate, in chylous stula,
430
Etomidate, 60
External iliac artery, inguinal hernia repair
related injury to, 518
External iliac vein, inguinal hernia repair
related injury to, 518
Extubation, after tracheal resection, 751
F damage control surgery and, 807
Factor V deciency, 40t
Factor VII deciency, 40t
Factor X deciency, 40t
Factor XI deciency, 40t
Factor XIII deciency, 40t
Falciform ligament, division of
in damage control surgery, 801
right hepatectomy and, 330331, 331f
Familial adenomatous polyposis, 44t
Familial hypocalciuric hypercalcemia, 407
Family history, documentation of, 4345,
44t45t
Fatty liver, laparoscopic gastric bypass and,
201202
Fear, 23, 4
Fecal stula, aortobifemoral bypass and, 603
Fecal incontinence, Hirschsprungs disease
repair and, 834
Feedback, 2122
Feeding
after enterectomy, 245
after pyloromyotomy, 874
tube. See Gastrostomy feeding tube;
Jejunostomy feeding tube
Femoral artery
cannulation of, 131, 132f
hernia repairrelated injury to, 505506
Femoral nerve
inadvertent block of, 54
injury to
aortobifemoral bypass and, 600
Femoral nerve (Continued)
infrainguinal revascularization and, 614
615
rectal resection and, 273274, 274f
Femoral vein
catheterization of, 110, 111f
injury to
greater saphenous vein ablation and,
645647
inguinal hernia repair and, 505
for pulmonary artery catheterization, 122
Femoral venous cannula, in abdominal venous
injury, 765766
Fentanyl, 29t, 50t
Fetus, malformation in, 6263
Fibrin sealant
in splenorrhaphy, 792
in trisectionectomy, 347348, 354
Finger block, 53t, 5455, 55f
Finney pyloroplasty, 167, 168, 171, 171f
Fish-tail plasty, 481, 481f
Fistula
anorectal. See Anorectal malformations
aortoenteric, abdominal aortic aneurysm
repair and, 609
arteriovenous
inferior vena cava lter placement and,
649
residual, infrainguinal revascularization
and, 617618
bronchocutaneous, chest tube insertion and,
138139
bronchopleural
chest tube insertion and, 138139
pneumonectomy and, 698699, 698f,
699f
chylous
adrenalectomy and, 430
mastectomy and, 485
supraclavicular lymph node biopsy and,
584
enteroatmospheric, damage control surgery
and, 806
enterocutaneous
epigastric hernia repair and, 527528
ileostomy and, 253, 253f
incisional hernia repair and, 533, 535f,
536, 540
inguinal hernia repair and, 504
laparotomy and, 9294, 94f
umbilical hernia repair and, 527528
esophagopleural, pneumonectomy and,
695
fecal, aortobifemoral bypass and, 603
gastrocutaneous, splenectomy and, 793794
ileovaginal, inguinal hernia repair and, 507
lymphatic, aortobifemoral bypass and, 600
mesh to skin, in incisional hernia repair,
533, 534f
pancreatic, 782783
pancreatectomy and, 377378
pancreaticoduodenectomy and, 367,
370371
pancreaticocutaneous, 388
perineal, 828, 828f, 828t
rectovaginal
hemorrhoidectomy and, 311, 312
rectal resection and, 286
rectovesical, 831, 832f
rectovestibular, 828, 828f
tracheoesophageal. See Tracheoesophageal
stula
Fistula-in-ano. See Anal stulotomy
Fitts and Posner, skill acquisition model of, 6
8, 6f, 7f
INDEX 885
Flank bulge, aortobifemoral bypassrelated,
604
Flat epithelial atypia, of breast, 449450, 450f
Fluid, ascitic, 143146. See also Paracentesis
Fluid imbalance, paracentesis and, 145146
Fluid therapy
in acute renal failure, 36
in component separation procedure, 554
in congestive heart failure, 32
in damage control surgery, 803804
Flumazenil, 50t, 52
Fluorescence in situ hybridization (FISH), for
HER-2 detection, 447448
Focused abdominal sonography for trauma
(FAST), 769, 770f
Foley catheter, 84
Foramen ovale, patent, 701702, 702f
Forced expiratory volume in 1 second (FEV1),
34
Foreign body, after damage control surgery
closure, 805806
Fracture, adrenalectomy and, 426
G
Gallbladder
cholecystectomy-related perforation of, 323
left-sided, in right hepatectomy, 335336
Gardner syndrome, 44t
Gas bloat syndrome, laparoscopic Nissen
fundoplication and, 180
Gas embolism
laparoscopic gastric bypass and, 198199
laparoscopic surgery and, 102
Gastrectomy, 223233
afferent loop syndrome after, 230
anastomotic bleeding with, 229
anastomotic leak with, 227229, 228b
anastomotic stricture after, 230231
Bancroft closure for, 225, 226f
bile reux gastritis after, 231232, 232f
complications for, 229233
delayed gastric emptying after, 232233
dumping syndrome after, 232
duodenal stump blow-out with, 225
duodenum transection for, 224226, 225f
efferent loop syndrome after, 230
esophageal transection for, 226
gastric vessel ligation for, 226
gastroesophageal junction exposure for, 226
incision for, 224
indications for, 223
left gastric artery in, 226, 227f
left gastroepiploic ligation for, 226
lymphadenectomy for, 226227
middle colic vessel injury with, 224, 224f
Nissen closure for, 225, 226f
nutritional decits after, 233
preoperative considerations in, 223224
reconstruction after, 227229, 227t, 228f,
229f
retain gastric antrum with, 225
Roux stasis syndrome after, 231, 231f
steps in, 223
Gastric antrum, retained, 225
Gastric artery
in gastrectomy, 226, 227f
injury to
gastrostomy tube and, 151152
splenectomy and, 575
ligation of, 226
Gastric bypass, laparoscopic, 197221
abdominal wall hernia and, 202
adhesions and, 202
anastomotic hemorrhage with, 216
anastomotic ischemia with, 209
 886 INDEX
Gastric bypass, laparoscopic (Continued)
anastomotic leak with, 215216, 215f
anastomotic obstruction with, 208
anastomotic stenosis with, 216217
anastomotic tension with, 216
anastomotic ulcer with, 217
arrhythmia with, 199
biliopancreatic limb misidentication with,
205
bowel misalignment with, 205206
bowel obstruction after, 217218
bowel stapler perforation with, 206207,
207f
cirrhosis and, 201202
colon injury with, 213
double-stapling technique for, 207, 207f
enteroenterostomy for, 205208, 207f,
208f
enteroenterostomy stenosis with, 207208,
208f
enterolysis for, 202203
failed mesentery closure with, 209
fatty liver and, 201202
gas embolism with, 198199
gastric injury with, 213
gastric pouch creation for, 209213
gastrojejunostomy for, 215216, 215f
gastrojejunostomy leak in, 215216
hemorrhage with
abdominal wall, 220221
anastomotic, 216
enterolysis-related, 203
mesenteric, 204205, 208209, 213, 219
staple line, 211
trocar-related, 200201
inadequate gastric division with, 212
indications for, 197
internal hernia with, 217218
lesser curvature hemorrhage with, 209
marginal anastomotic ulcer with, 217
mesenteric defect closure for, 208209
mesenteric hemorrhage with, 204205,
204f, 208209, 213, 219
missed abdominal lesion with, 201
organ injury with, 200, 202203
organ survey for, 201202
Petersens space hernia with, 218219
pneumoperitoneum for, 198201
port misplacement with, 201
port site closure for, 220221
pouch creation for, 209213, 210f
proximal jejunum misidentication with,
203
proximal pouch ischemia with, 212213
Richters hernia with, 220
Roux-en-Y limb creation for, 203205
Roux-en-Y limb hematoma with, 219220
Roux-en-Y limb length inadequency with,
205, 213214
Roux-en-Y limb misidentication with, 205
Roux-en-Y limb obstruction with, 214215
Roux-en-Y limb passage for, 213215, 214f
Roux-en-Y limb stenosis with, 219
Roux-en-Y limb twisting with, 214
small bowel injury with, 203204
small bowel ischemia with, 204
staple line hemorrhage with, 211
staple line leak with, 212
stapler defect closure for, 207, 207f
stapler misre with, 206, 211, 215
steps in, 197198
subcutaneous emphysema with, 199200
too-large pouch with, 210
too-proximal gastric division with, 209210
triple stitch technique for, 218, 218f
trocar-related injury with, 200201
Gastric bypass, laparoscopic (Continued)
tube stapling with, 210211
twisted Roux-en-Y limb with, 214, 214f
vascular injury with, 198, 200201
Veress needle insertion in, 198
viscus injury with, 198, 202203
Gastric emptying, delayed
gastrectomy and, 232233
left hepatectomy and, 342
pancreaticoduodenectomy and, 371372
Gastric vessel ligation
in laparoscopic esophagomyotomy with Dor
fundoplication, 189
in laparoscopic Nissen fundoplication, 179
180, 179f, 180f
Gastric volvulus, left hepatectomy and, 342
343
Gastrocutaneous stula, splenectomy and,
793794
Gastroduodenal artery,
pancreaticoduodenectomy-related division
of, 371
Gastroepiploic artery, ligation of, 226
Gastroesophageal junction dissection
in gastrectomy, 226
in laparoscopic Nissen fundoplication, 176
178, 177f
Gastroesophageal reux
esophageal atresia repair and, 854855
gastrectomy and, 233
laparoscopic esophagomyotomy with Dor
fundoplication and, 192194, 193f
Gastrojejunostomy, stenosis of, laparoscopic
gastric bypass and, 216217
Gastrostomy feeding tube, 147154
incision for, 148
indications for, 148
open placement of, 148150
Janeway, 148, 150
stoma maturation for, 150
tract creation for, 150
tube creation for, 150
tube diameter inadequacy with, 150
tube eversion inadequacy with, 150
tube insertion for, 150
tube length inadequacy with, 150
tube position inadequacy with, 150
Stamm, 148150
bowel perforation with, 148
gastric tearing with, 149
gastric wall injury with, 149
inadequate suture thickness with, 148
intra-abdominal injury with, 148
steps in, 148
tract loss with, 149
tube damage with, 149
tube dislodgement with, 149150
percutaneous placement of, 150153
abdominal wall injury with, 153
angiocatheter insertion for, 151152
bumper placement for, 153
endoscopy for, 151, 152, 152f, 153,
153f, 154
gastric distention inadequacy with, 151
gastric vessel injury with, 151152
guidewire capture for, 152, 153f
guidewire loss with, 152, 153f
intestinal injury with, 151
one-to-one position for, 151, 152f
steps in, 150151
tongue laceration with, 152, 152f
tract loss with, 152153
tube pull-through for, 153
visceral perforation with, 151152
Gastrotomy, anterior, 383384
Genetic syndromes, 4345, 44t45t
Gladwell, Malcolm, 5, 5f
Glasgow Coma Score
in trauma, 763764, 764t
in traumatic brain injury, 785, 786t
Goals, operative, in technical skills instruction,
1516
Gonadal artery, colectomy-related injury to,
267268
Goodsalls rule, in anal stulotomy, 316, 316f
Graham patch repair, 159164
drainage after, 163
duodenal stenosis and, 160161
exposure for, 160
fascial closure for, 163
Helicobacter pylori infection and, 163164
incision for, 160
indications for, 159
irrigation for, 160
laparoscopic, 160
omental insufciency with, 162163
omental mobilization for, 161162, 162f
omental strangulation with, 162163
omental tongue necrosis with, 161162
perforation enlargement in, 160
reperforation and leak risk after, 164, 164b
sealed perforation and, 159, 160
skin closure for, 163
steps in, 159160
sutures for, 160161, 161f, 162163, 162f,
163f
trocar-related injury with, 160
viscera injury with, 160
Greater omentum
deciency of, in Graham patch repair, 162
163
necrosis of, in Graham patch repair, 161
162, 162f
strangulation of, in Graham patch repair,
162, 162f, 163f
Greater saphenous vein
ablation of, 645647, 646f
incomplete ligation of, 645
ligation of, 645
stripping of, 643645, 644f
Guidewire loss, with central vein
catheterization, 115, 115f
Gunshot wound
damage control surgery for. See Damage
control surgery
incorrect assessment of, 767
to neck, 809
H
Hand
ischemia of, radial artery cannulation and,
131
paresthesia of, axillary artery cannulation
and, 131, 133f, 134
Harmonic scalpel, in mastectomy, 479
Heart, injury to
central vein catheterization and, 115116
laparoscopic Nissen fundoplication and, 184
pectus excavatum repair and, 842, 845
Heart failure, congestive, 3032
Heart rate, trauma-related, 763
Heineke-Mikulicz pyloroplasty, 167168,
170f, 171
Hematoma
abdominal wall
laparoscopic gastric bypass and, 220221
laparoscopic surgery and, 200201
axillary dissection and, 467468
breast
image-guided biopsy and, 445446, 445f
open biopsy and, 458

Hematoma (Continued)
central vein catheterization and, 112113,
113f
component separation procedure and, 567
enterectomy and, 240
epigastric hernia repair and, 527
hepatic, laparoscopic Nissen fundoplication
and, 184
inferior vena cava lter placement and, 649
infrainguinal revascularization and, 625626
mastectomy and, 479, 485
mesenteric, jejunostomy and, 156
pyloromyotomy and, 874
retroperitoneal
damage control surgery and, 801802
laparoscopic splenectomy and, 579
laparoscopic surgery and, 99100, 100f
Roux-en-Y limb, laparoscopic gastric bypass
and, 219220
saphenous nerve stripping and, 643, 645
subdural, in traumatic brain injury, 788
789, 788f
thyroid surgery and, 404
umbilical hernia repair and, 527, 869
Hemobilia, cholecystectomy-related, 323
Hemodialysis access. See Arteriovenous
hemodialysis access
Hemophilia A, 40t
Hemophilia B, 40t
Hemorrhage. See Bleeding; Hematoma
Hemorrhoidectomy, 307313
stapled, 310313
hemorrhage after, 313
inadequate excision with, 311312
incomplete excision with, 312313
indications for, 310
pain after, 311, 312
pursestring suture for, 311312, 311f
rectovaginal stula with, 311, 312
stapler ring for, 312, 312f
stapler removal for, 312313, 313f
steps in, 310
stricture after, 311, 312
traditional, 307310
anal stenosis with, 308, 309
anesthesia for, 307308
anoscopy for, 308
closure for, 310
hemorrhage with, 308, 310
Hill-Ferguson retractor for, 309, 310f
inadequate excision with, 309310
inadequate planning for, 308
indications for, 307
pedicle excision for, 308310, 309f, 310f
pedicle ligation for, 308, 308f
pedicle religation for, 310
sphincter injury with, 308309
steps in, 307
urinary retention after, 307308
Whitehead deformity after, 310
Hemostasis
in axillary dissection, 467468
in laparoscopic splenectomy, 579
in thyroid surgery, 403404
Hemothorax
thoracic trauma and, 774, 774f, 777
ultrasound image-guided breast biopsy and,
444
Henley procedure, 231, 232
Heparin, for infrainguinal revascularization,
621622
Hepatectomy
cholecystectomy and, 325327, 325f, 326f
bile leak with, 326327
bleeding with, 326
closure for, 325
Hepatectomy (Continued)
cystic artery resection for, 324325
cystic duct resection for, 324325
nodal resection for, 327
portal vein injury with, 327
extended. See Trisectionectomy
laparoscopic, 359366
air embolism with, 365366
bile leak with, 365
bleeding with, 364365
closure for, 365
hand-assist technique for, 360, 360f
hypotension with, 365
inadequate space for, 362
indications for, 359
liver mobilization for, 361362, 362f
parenchymal division for, 362365, 363f,
364f
patient positioning for, 359360, 360f
pneumothorax with, 362
port placement for, 360361, 360f, 361f
steps in, 359
trocar-related bleeding with, 361
ultrasonography for, 362, 363f
viscus injury with, 361
left, 339344
caudate portal vein injury with, 341, 342f
delayed gastric emptying with, 342
esophageal injury with, 339340, 340f
extended. See Trisectionectomy
falciform ligament division for, 339
gastric perforation with, 341
gastric volvulus with, 342343
hepatic vein division for, 344
hepatogastric ligament division for, 340
341, 341f
incision for, 339
indications for, 339
inferior vena cava injury with, 339
left coronary ligament division for, 339
340, 340f
left hepatic artery injury with, 340341,
341f
left hepatic artery ligation and division
for, 341
left hepatic duct division for, 343, 343f
left portal vein ligation and division for,
341, 342f
left triangular ligament division for, 339
340
parenchymal division for, 342343
right hepatic duct injury with, 343
splenic injury with, 344
steps in, 339
right, 329338
adrenal gland injury with, 332333
air embolism with, 331332
bile leak with, 337338
blood loss with, 336337
central venous pressure in, 337
common hepatic duct compromise with,
334
diaphragm injury with, 332
duodenal injury with, 332
epigastric vessel bleeding with, 330
extended. See Trisectionectomy
hepatic vein bleeding with, 336
hepatic vein division for, 333, 333f, 334f
hepatic vein injury with, 331332, 336
hernia with, 329330
incision for, 329330, 330f
inferior vena cava injury with, 331332,
333
isovolemic hemodilution in, 337
left lobe torsion with, 330331
left-sided gallbladder in, 335336
INDEX 887
Hepatectomy (Continued)
ligament division for, 330333, 331f,
332f
parenchymal transection for, 336337,
337f
phrenic vessels in, 333
porta hepatis dissection for, 333336,
334f, 335f
posterior portal vein injury with, 335,
335f, 336f
Pringle maneuver in, 337
replaced right hepatic artery in, 334, 335f
right hepatic duct division for, 337338
right hepatic vein division for, 334, 334f,
336
right portal vein division for, 334335,
335f
steps in, 329
suprahepatic inferior vena cava injury
with, 331332
Hepatic artery
common, biliary resectionrelated injury to,
392
injury to, cholecystectomy and, 321322
left
injury to
biliary resection and, 392393
hepatectomy and, 340341, 341f
replaced, 340341, 341f
right
division of, 334, 334f
injury to
biliary resection and, 392393
pancreaticoduodenectomy and, 368
replaced, 334, 334f, 335f, 368, 393,
393f
Kocherization-related injury to, 781
782
trisectionectomy-related injury to, 348349
Hepatic duct
common, hepatectomy-related compromise
of, 334
resection-related leak from, 395
right
division of, 337338
hepatectomy-related injury to, 343
Hepatic exure
adrenalectomy-related injury to, 428
mobilization of, in right colectomy, 260
261, 261f
Hepatic vein(s)
left, division of, 344
middle, division of, 344
right, division of, 336
short, in right hepatectomy, 333, 333f
trisectionectomy-related injury to, 349350
Hepatogastric ligament, division of, 175176,
176f
HER-2 immunostain, on breast biopsy, 447
448, 448f
Hereditary nonpolyposis colorectal cancer, 44t
Hernia
after damage control surgery, 807
diaphragmatic
congenital, 857860
repair of, 857860
anesthesia for, 857
chest tube for, 860
chylothorax with, 860
compartment syndrome with, 860
extralobar pulmonary sequestration
inspection for, 858, 858f
sac excision for, 858
skin preparation for, 857858
solid organ injury with, 858
steps in, 857
 888 INDEX
Hernia (Continued)
tension-free closure for, 858860,
859f
tidal volume monitoring for, 860
visceral reduction for, 858
postesophagectomy, 738739
epigastric
recurrence of, 525526
repair of, 523528
abscess after, 527528
enterocutaneous stula with, 527528
hematoma with, 527
infection with, 527
laparoscopic, 525, 526f
mesh for, 523525, 524f525f, 526f
open, 523, 525f
seroma with, 526527
skin necrosis with, 528
incisional
cholecystectomy-related, 325
laparoscopic repair of, 537542
adhesiolysis for, 538, 539f, 540f
bleeding with, 538
contraindications to, 537
enterocutaneous stula with, 540
ileus after, 541
indications for, 537
infection with, 539540
intestinal injury with, 539
mesh migration with, 542
mesh placement for, 539541
reduction for, 539
seroma with, 541
small bowel perforation with, 542,
542f
steps in, 537
suture site pain with, 541542
trocar placement for, 537, 538f
misdiagnosis of, 531
off-midline, 534f, 535
open repair of, 531536
abdominal wall loss with, 536
adhesiolysis for, 533
bowel obstruction and, 534535
closure for, 534
deserosalization with, 533
domain loss with, 536
enterocutaneous stula and, 533, 535f,
536
enterotomy with, 533
fascial edge denition for, 532533,
533f
infection and, 531, 532, 532f
mesh placement for, 533534, 534f
contraindications to, 531, 532f
stula with, 533534, 534f
mesh to skin stula with, 533534,
534f
in off-midline hernia, 534f, 535
preoperative considerations in, 531
532
seroma with, 534, 534f
steps in, 532
timing of, 534536
recurrence of, 531533, 533f, 540541,
541f
surgical history and, 531
inguinal, 515, 516f
iatrogenic, 868869
laparoscopic repair in, 515521
bladder injury with, 517
bleeding with, 517
contraindications to, 515
Coopers ligament in, 517, 517f
in direct hernia, 517518, 517f, 518f,
520, 520f
Hernia (Continued)
external iliac vessel injury with, 518
indications for, 515
in indirect hernia, 518519, 519f, 520f
inferior epigastric vessel injury with,
518
mesh placement for, 519520, 520f,
521f
nerve injury with, 520, 521f
positioning for, 516
pseudosac in, 517518, 518f
pubic bone exposure for, 517
steps in, 515516
trocar insertion for, 516, 516f
open repair in, 501507
bowel obstruction with, 506
closure for, 506
contraindications to, 501, 502b
enterocutaneous stula with, 504
external oblique fascia incision for,
502, 503f
failure of, 504
femoral vessel injury with, 505506,
506f
hemorrhage with, 502503
ileovaginal stula with, 507
ilioinguinal nerve block in, 53, 54f
ilioinguinal nerve injury with, 502,
505, 505f
indications for, 501, 502b
ischemic orchitis with, 502
mesh xation for, 503506, 504f,
505f, 506f
mesh infection with, 503
mesh migration with, 506, 507f
pain after, 505
paravesical abscess with, 507
recurrence after, 504
Scarpas fascia dissection for, 502
seroma with, 506, 506f
spermatic cord mobilization for, 502
503, 503f
steps in, 501502
subcutaneous layer dissection for, 502
testicular injury with, 502
vas deferens obstruction with, 504
505
vasogram after, 504
pediatric, repair of, 867869
contralateral exploration for, 868
cremaster entrapment with, 868
external oblique aponeurosis closure
for, 868
external oblique aponeurosis division
for, 867
iatrogenic direct inguinal hernia with,
868869
iliohypogastric nerve injury with, 867
ilioinguinal nerve injury with, 867
incomplete pneumoperitoneum
evacuation with, 868
sac ligation for, 868, 868f
sac separation for, 867
sac tear with, 868
sliding organ injury with, 868
spermatic vessel injury with, 867
steps in, 867
vas deferens injury with, 867
prolene system in, 509512, 510f
external pocket development for, 510
511, 511f
hernia type conrmation for, 510
incision for, 509510
indications for, 509
onlay component positioning for, 512,
512f
Hernia (Continued)
posterior space preparation for, 511,
511f
steps in, 509
suture placement for, 512
underlay patch deployment for, 511
512, 512f
recurrence of, 504
internal, in laparoscopic gastric bypass, 217
218
lumbar, adrenalectomy and, 431, 431f
paraesophageal
laparoscopic esophagomyotomy with Dor
fundoplication and, 189, 189f
postesophagectomy and, 738739
Petersens space, laparoscopic gastric bypass
and, 218219
Richters, laparoscopic gastric bypass and,
220
spigelian, 559560
stomal
colostomy and, 297
ileostomy and, 250, 250f
umbilical, 523528
in end-stage liver disease, 528, 528f
pediatric, 869, 869f
recurrence of, 525526
repair of, 523528
abscess after, 527528
enterocutaneous stula with, 527528
hematoma with, 527
infection with, 527
laparoscopic, 525, 526f
mesh for, 523525, 524f525f, 526f
open, 523, 525f
seroma with, 526527
skin necrosis with, 528
ventral (abdominal wall). See also Hernia,
incisional
hepatectomy-related, 329330
laparoscopic gastric bypass and, 202
reconstruction for. See Abdominal wall
reconstruction, component
separation in
repair-related visceral injury with, 76, 77f
Heuristics, 34
Hill-Ferguson retractor, in hemorrhoidectomy,
309, 310f
Hirschsprungs disease, 832835, 832f
clinical presentation of, 832
repair in, 833835
aganglionic bowel resection for, 833834
anastomotic leak with, 833834
Duhamel, 833
enterocolitis with, 834
incontinence with, 834
intestinal twisting with, 833, 834f
nervi erigentes injury with, 833
residual aganglionosis after, 835
Soave-Boley, 833
steps in, 833
stricture with, 834
submucosal dissection in, 833
Swenson, 833
in total colonic disease, 834835, 835f
Hoarseness, postesophagectomy, 734735
Horners syndrome, pectus excavatum repair
and, 843
Horseshoe kidney, 610
Hourglass tumor, 721, 721f
Hydrocodone, 29t
Hydrogen peroxide injection, in anal
stulotomy, 316, 316f
Hydromorphone, 29t, 50t
Hydrothorax, thymectomy and, 720
Hypercoagulable state, 39, 4142, 42t

Hyperglycemia, 4243, 43b Ileostomy (Continued)
Hyperhomocystinemia, 45t stoma maturation for, 253
Hyperkalemia, after succinylcholine stoma misplacement with, 247, 248f
administration, 5859, 58b stoma necrosis/ischemia with, 249, 249f
Hyperparathyroidism, 407 stoma prolapse with, 250
in cancer, 419 stoma retraction with, 248249
in genetic disease, 418419 stoma stenosis with, 249, 249f
surgery for. See Parathyroidectomy stoma varices with, 254
Hyperparathyroidjaw tumor syndrome, 418, Ileovaginal stula, inguinal hernia repair and,
419 507
Hypertension Ileus
intra-abdominal, 805806 component separation procedure and, 553
intracranial, traumatic brain injury and, 787, 554
787b enterectomy and, 245
venous, arteriovenous access and, 635636 incisional hernia repair and, 541
Hyperthermia, malignant, 59, 59t Iliac artery, colectomy-related injury to, 267
Hyperthyroidism, iatrogenic, 404 268, 268f
Hypertrophic pyloric stenosis, 871. See also Iliohypogastric nerve, hernia repairrelated
Pyloromyotomy injury to, 510, 867
Hypocalcemia Ilioinguinal nerve
hypoparathyroidism and, 400 in inguinal hernia repair, 502, 503f
parathyroidectomy and, 413 inguinal hernia repairrelated injury to, 502,
Hypobrinogenemia, 40t 505, 505f, 510, 867
Hypogastric nerve, in low anterior resection, Ilioinguinal nerve block, 53, 54f
282283, 282f Immunization
Hypoglossal nerve, carotid endarterectomy after splenectomy, 794
related injury to, 589, 589f before splenectomy, 572, 580
Hypoparathyroidism Imperforate anus. See Anorectal malformations
iatrogenic, 418 Indocyanine green test, in trisectionectomy,
thyroid surgery and, 400401, 401t 355
Hypotension Induction
adrenal insufciency and, 43 aspiration during, 63
in blunt trauma patient, 769770 hypotension and, 60
damage control surgery and, 801 Infection
induction and, 60 abdominal aortic aneurysm repair and, 609
intraoperative, in laparoscopic hepatectomy, abdominal perineal resection and, 294295
365 appendectomy and, 300302, 303305
medication-related, 52 arteriovenous access and, 639, 639f
posttraumatic, 764 breast biopsy and, 475476
Hypothermia catheter
damage control surgery steps for, 803804 axillary artery cannulation and, 131
posttraumatic, 764765 central vein catheterization and, 116
Hypothyroidism, iatrogenic, 404 radial artery, 129130
Hypovolemia, in traumatic brain injury, 788 chest wall, 714715
Hypoxemia, in pregnancy, 62 cholecystectomy and, 325
Hypoxia, trauma-related, 757, 760 colectomy and, 263
component separation procedure and, 554,
567
I enterectomy and, 239, 239f
Ileostomy, 247254 epigastric hernia repair and, 527
abdominal wallfascial incision alignment incisional hernia repair and, 532, 532f
for, 250, 250f, 251f, 252f infrainguinal revascularization and, 619
bowel injury with, 250, 251 620, 626627, 626t, 627f
bowel passage for, 251, 253, 253f laparoscopic incisional hernia repair and,
bowel segment selection for, 247249 539540
bowel twisting with, 251, 253 laparotomy and, 9294, 93f, 94f
carcinoma of, 254 mesh, in open inguinal hernia repair, 503
component separation procedure and, 548, pancreatic. See Pancreatic necrosis
550f551f paracentesis and, 145
diversion colitis with, 254 pectus excavatum repair and, 842, 847
end-loop, 247, 248f pyloromyotomy and, 874
enterocutaneous stula with, 253, 253f sentinel lymph node biopsy and, 471
fascial incision for, 250, 250f, 251f, 252f splenectomy and, 580, 794
high-output stoma with, 247248 sternal wound, 714715
indications for, 247 trisectionectomy and, 353
inferior epigastric vessel injury with, 250 umbilical hernia repair and, 527
mucocutaneous separation with, 249 wound, 37, 37t
peristomal hernia with, 250, 250f, 251f, appendectomy and, 300301
252f chest tube insertion and, 136
pyoderma gangrenosum with, 254 colectomy and, 263
rectus ber separation for, 250, 252f esophagectomy and, 737
site selection for, 247, 248f laparoscopic gastric bypass and, 37, 37t, 220
skin incision for, 249 laparotomy and, 8788
steps in, 247 sternal, 714715
stoma bowel passage for, 251, 253, 253f Inferior epigastric artery, ileostomy-related
stoma incision for, 250, 250f injury to, 250, 252f
INDEX 889
Inferior polar arteries, splenctomy-related
injury to, 575
Inferior vena cava
injury to
abdominal aortic aneurysm repair and,
607609
adrenalectomy and, 426
aortobifemoral bypass and, 602
left hepatectomy and, 339
pancreaticoduodenectomy and, 368
right hepatectomy and, 331332, 331f,
333, 333f, 334f
trisectionectomy and, 349350
in neuroblastoma resection, 864865, 865f
suprahepatic, hepatectomy-related injury to,
331332, 331f
Inferior vena cava lter placement, 41, 42,
648649, 648f
Informed consent, 23
documentation of, 24
steps for, 13
Infrainguinal revascularization, 613628
anastomotic dehiscence with, 622
anastomotic narrowing with, 622
anticoagulation for, 621622
bleeding with, 621, 625626, 626f
closure for, 625627, 627f
common peroneal nerve injury with, 616
conduit preparation for, 616620, 617f,
618f, 619f
conduit tunneling for, 620621, 620f
deep peroneal nerve injury with, 616
deep venous thrombosis after, 628
distal anastomosis for, 622624, 623f
distal artery exposure for, 615616, 616f,
617f
evaluation for, 613614
failed venous valve lysis with, 618619,
619f
femoral nerve injury with, 614615, 615f
graft failure with, 624625, 627
graft kinking with, 620621
improper inow artery choice with, 614
inadequate anticoagulation for, 621622
indications for, 613, 614
infection with, 619620, 626627, 626t,
627f
intimal dissection with, 622
intimal hyperplasia with, 624, 624f
intra-arterial plaque embolization with, 622
intraoperative evaluation for, 624625, 625f
lymphatic leak with, 625
myocardial infarction and, 627628
pneumonia after, 628
proximal anastomosis for, 622, 623f
proximal artery exposure for, 614615,
614f
renal failure after, 628
residual arteriovenous stula with, 617618,
618f
respiratory failure after, 628
saphenous nerve injury with, 617
seroma with, 625
steps in, 614
stricture with, 621, 621f
supercial peroneal nerve injury with, 616
thrombosis with, 627
tibial nerve injury with, 616
vein mapping for, 617, 618f
vein spasm with, 617
venous injury with, 615616
wound closure for, 620, 620f
Intercostal nerve, injury to
chest tube insertion and, 138, 138f
component separation procedure and, 560
VATS lobectomy and, 672673
 890 INDEX
Intercostal vessels, injury to
chest tube insertion and, 138
chest wall resection and, 712
pectus excavatum repair and, 841842
Intercostobrachial nerve, dissection-related
injury, 466467, 466f, 467f
Internal mammary vessel, pectus excavatum
repairrelated injury to, 841842
Intestinal malrotation, 819825
delayed diagnosis of, 821
development of, 819820, 820f
diagnosis of, 820821, 821f
Ladd procedure for, 821, 822f
delayed, 821
mesentery injury with, 823
recurrent volvulus after, 822823
small intestinal obstruction after, 823
Intestine. See Colon; Small intestine
Intimal hyperplasia
arteriovenous access and, 635, 636f
infrainguinal revascularization and, 624,
624f
Intracranial hypertension, traumatic brain
injury and, 787, 787b
Intraosseous needle placement, in trauma,
765
Intubation. See also Airway
in cervical spine injury, 58
in children, 63
main stem, in trauma, 762
in pregnancy, 62
in trauma, 762
in traumatic brain injury, 785, 786t
Intussusception, 824
Ischemia
anastomotic, in laparoscopic gastric bypass,
209
biliary, trisectionectomy-related, 349
colonic, ruptured abdominal aortic
aneurysm and, 611
conduit, esophagectomy and, 735
end-organ, 52
epinephrine-related, 52
extremity, abdominal aortic aneurysm repair
and, 607
ap, component separation procedure and,
554, 555f557f
foregut, pancreaticoduodenectomy and,
371, 371f, 372f
graft, abdominal aortic aneurysm repair and,
609
hand, radial artery cannulation and, 131
proximal gastric pouch, laparoscopic gastric
bypass and, 212213
rectal, pediatric colostomy and, 830831
small intestine
in children, 825
cholecystectomy and, 323324
laparoscopic gastric bypass and, 204, 209
malrotation and, 821
stoma, ileostomy and, 249, 249f
testicular, inguinal hernia repair and, 502
Ischemic monomelic neuropathy, 638
Isolated limb perfusion. See Melanoma,
isolated limb perfusion in
Isosulfan blue dye, in sentinel node biopsy,
468, 469, 469f, 470, 470f
Isovolemic hemodilution, in right
hepatectomy, 337
J fundoplication, laparoscopic
Jaboulay pyloroplasty, 167, 168, 171
Janeway gastrostomy feeding tube. See
Gastrostomy feeding tube, open
placement of, Janeway
Jejunostomy feeding tube, open placement of,
155157
epigastric vessel injury with, 156157
hematoma with, 156
incision for, 155
indications for, 155
intra-abdominal injury with, 155
jejunal wall injury with, 156
jejunum identication for, 155156
ligament of Treitz misidentication with,
155156
pursestring suture for, 156
steps in, 155
suture inadequacy with, 156, 157
sutures for, 157
tube dislodgment with, 156, 157
tube placement for, 156157
Jejunum
jejunostomy-related injury to, 156
misidentication of, in laparoscopic gastric
bypass, 203
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), 2
Jordan, Michael, 6
Jugular vein
catheterization of, 109, 111f
for pulmonary artery catheterization, 122
Juvenile polyposis syndrome, 44t
K Maddox maneuver in, 67, 69f
Kanizsa triangle, 3, 4f
Ketamine, 50t, 60
Ketorolac, 50t
Kidneys
adrenalectomy-related injury to, 430431
assessment of, 3637, 36b
drug effects on, 36, 36b
horseshoe, 610
infrainguinal revascularizationrelated failure
of, 628
Kocher incision, 70
Kochers maneuver, 368, 780782, 780f, 781f
inadequate/incomplete, in pyloroplasty,
172
in lateral pancreaticojejunostomy, 380
Kosslyn, Stephen, 5
L to, 466467
Ladd procedure, 821, 822f
bowel obstruction after, 824825
delayed, 821
mesentery injury with, 823
recurrent volvulus after, 822823
small intestinal obstruction after, 823
Laparoscopic surgery, 97103
abdominal entry for, 97100, 98f
arrhythmias with, 101
bowel injury with, 9799, 98f
cardiovascular complications of, 100101
deep vein thrombosis with, 103
for esophagomyotomy. See
Esophagomyotomy, laparoscopic
gas embolism with, 102
for gastric bypass. See Gastric bypass,
laparoscopic
Hasson entry technique for, 97
hemodynamic complications of, 103
macrobracing for, 99, 99f
for Nissen fundoplication. See Nissen
patient positioning for, 101
pneumothorax with, 101102
port site bleeding with, 100
renal complications of, 102103
Laparoscopic surgery (Continued)
retroperitoneal hematoma with, 99100,
100f
rhabdomyolysis with, 102103
splanchnic circulation effects of, 103
steps in, 97
ventilation-perfusion mismatch with, 102
Veress needle insertion for, 97, 98, 98f, 99
Laparotomy, 6795
abdominal compartment syndrome and, 89
91, 90f, 91f
adhesions during, 7172, 7374, 74f, 75
76, 75f, 76f
bladder injury with, 8284
Catell and Braasch maneuver in, 67, 69f
closure for, 67, 69f, 8589, 87f, 88f, 89f
denervation injury with, 7071, 72f
embryology and, 67, 68f
enterocutaneous stula after, 9294, 94f
esophageal injury with, 8182, 83f
facial closure for, 8589, 87f, 88f, 89f
incisional planning for, 67, 70, 7172
infectious complications of, 8788, 9294,
93f, 94f
intestinal injury with, 7475, 75f, 76f
intestinal obstruction after, 9495
intra-abdominal abscess after, 9294, 93f
Kocher incision for, 70
linea alba in, 73, 73f
liver injury with, 78
muscle-splitting appendectomy incision for,
70, 71f
needlestick injury with, 89, 89f
nerve injury with, 7071, 72f
peritoneal cavity identication for, 7374,
73f, 74f
Pfannenstiel incision for, 70, 72f
splenic injury with, 7881, 79f
sutures for, 87, 87f, 8889, 88f
ureter injury with, 82
vacuum-assisted closure for, 91, 91f
vascular injury with, 7071, 8485, 85f, 86f
wound dehiscence with, 8586
wound evisceration with, 8586
wound infection with, 8788
Laryngotracheal examination, in neck injury,
815816
Lateral pectoral nerve, dissection-related injury
Leape, Lucian, 2, 2f
Learning needs assessment, in technical skills
instruction, 1314
Left hepatic artery, aberrant, injury to, in
Nissen fundoplication, 175176, 176f
Left renal vein, retroaortic, 610
Left triangular ligaments, hepatectomy-related
division of, 330331
Legal considerations, 2326
Lesser sac, laparotomy-related injury to, 78
81, 80f
Lidocaine, 50t
Ligament of Treitz
incorrect identication of, 155156
in laparoscopic gastric bypass, 203
Limb perfusion, isolated. See Melanoma,
isolated limb perfusion in
Line of Toldt, 8081, 82f
Linea alba, 73, 73f
Liposuction garments, after component
separation procedure, 568
Liver. See also Liver disease
caudate lobe of
blood ow to, 335336, 336f
ligamentous band of, 333, 333f, 334f
venous supply of, 341, 342f

Liver (Continued)
cholecystectomy-related injury to, 323
failure of, after trisectionectomy, 354356
fatty, laparoscopic gastric bypass and, 201
202
hematoma of, laparoscopic Nissen
fundoplication and, 184
laparotomy-related injury to, 78
left lobe torsion in, hepatectomy-related,
330331
mobilization of
in laparoscopic adrenalectomy, 426
in open adrenalectomy, 428, 429f
resection of. See Hepatectomy
Liver disease
screening for, 3436, 35t
umbilical hernia in, 528, 528f
Lobectomy
hepatic. See Hepatectomy
sleeve. See Bronchial and vascular sleeve
lobectomy
VATS. See Video-assisted thoracic surgery
(VATS) lobectomy
Local anesthetics, 50t
seizure with, 4950, 50t
in stereotactic image-guided breast biopsy,
438439
in ultrasound image-guided breast biopsy,
443444
Long thoracic nerve, injury to
axillary dissection and, 466467, 466f
tracheoesophageal stula repair and, 850
Lorazepam, 50t
Low anterior resection, 273287
anastomosis for, 283287, 284f
bleeding from, 285, 285f
leak from, 283285
stricture of, 285286
bladder dysfunction after, 282283
bladder injury with, 274275
bleeding with, 275277
bowel dysfunction after, 287
colon mobilization for, 275278, 276f,
277f, 278f, 284f
hemorrhage with, 279, 281282, 282f
hypogastric nerve identication for, 282,
282f
incision for, 274275, 275f
indications for, 273
mesenteric vessel ligation for, 275278,
276f, 277f
patient positioning for, 273274
peripheral nerve injury with, 273274, 274f
rectal mobilization for, 278283, 279f,
280f, 281f
rectovaginal stula with, 286
retractors for, 274, 274f, 279, 279f
sexual dysfunction after, 282283
steps in, 273
ureteral injury with, 277278, 286287
vaginal injury with, 286
Lumbar hernia, adrenalectomy and, 431, 431f
Lumpectomy. See Mastectomy, partial
Lungs
apex of, chest tube in, 140
cancer of, 671. See also Bronchial and
vascular sleeve lobectomy;
Pneumonectomy; Video-assisted
thoracic surgery (VATS) lobectomy
chest wall resection for, 709712, 710f,
711f
supraclavicular lymph node biopsy in,
583584
laceration of, chest tube insertion and, 138
139
soft tissue sarcoma metastasis of, 495
Lymph node biopsy
axillary. See Axillary dissection
sentinel. See Sentinel lymph node biopsy
supraclavicular, 583584
Lymphadenectomy
axillary. See Axillary dissection
before bronchial and vascular sleeve
lobectomy, 691
in gastrectomy, 226227
in pneumonectomy, 693695
at porta hepatis, 327
in VATS lobectomy, 682
Lymphatic leakage
aortobifemoral bypass and, 600
infrainguinal revascularization and, 625
pneumonectomy and, 693694
posterior mediastinal mass resection and,
723
VATS lobectomy and, 682
Lymphedema
axillary dissection and, 467
sentinel lymph node biopsy and, 469470
Lynch syndrome, 44t
M pectoral fascia preservation in, 479, 480
Macrobracing, 19, 99, 99f
Maddox maneuver, 67, 69f
Magnetic resonance imaging, in soft tissue
sarcoma, 491492, 491f, 492f
Malignant hyperthermia, 59, 59t
Malnutrition, 3839, 38f
after enterectomy, 245
Malrotation. See Intestinal malrotation;
Volvulus
Marginal mandibular nerve, carotid
endarterectomyrelated injury to, 589
590
Mastectomy
axillary dissection with, 465468, 466f,
467f
drain placement for, 468
hemostasis for, 467468
incision for, 465466
indications for, 465
lymphedema after, 467
nerve injury with, 466467, 466f, 467f
steps in, 465
technique of, 466467, 466f, 467f
partial, 458462
cosmetic outcomes of, 460, 461f, 462
false-positive margins with, 460
Faxitron for, 461f, 462
inadequate negative margins with, 459
462
incision for, 459, 460f
indications for, 458459
localization for, 459
resection for, 459460
specimen orientation for, 460, 462
specimen radiography in, 461f, 462
steps in, 459
sentinel lymph node biopsy with, 468471
allergic reaction with, 469
contraindications to, 468469
dissection for, 469470, 469f, 470f
failure of, 470, 471
false-negative, 470471
indications for, 468
infection after, 471
isosulfan blue dye for, 468, 469, 469f,
470, 470f
lymphedema after, 469470
nerve injury with, 469
palpable nodes in, 471
pulse oximeter reading with, 469
INDEX 891
Mastectomy (Continued)
seroma after, 469470
steps in, 469
total, 475485
antibiotics for, 476
biopsy before, 475476
blood transfusion with, 479
cancer recurrence after, 479480
chylous stula after, 485
closure for, 480484, 481f, 482f, 483f
crinkly layer in, 480, 480f
dissection extent for, 479480, 480f
drain for, 478
sh-tail plasty for, 481, 481f
ap elevation for, 477479, 480f
ap length measurement for, 482, 483f
ap necrosis with, 476477, 476f
ap recurrence after, 479
harmonic scalpel for, 479
hematoma after, 485
incision for, 476477, 477f, 478f
indications for, 475
inframammary fold in, 479, 480, 480f
omega incision for, 476, 477f
pain after, 479
pectoral nerves in, 484, 484f
pectoralis atrophy after, 484
phantom breast syndrome after, 485
pneumothorax after, 485
redundant skin with, 480482
seroma after, 477479
skin-sparing incision for, 477
steps in, 475
suture-associated issues in, 482, 484
V-Y advancement ap for, 481482,
482f
Mastery, stages of, 17, 17f
Mayo hernioplasty, 523, 524f
Median nerve block, 53t, 55, 56f
Mediastinal mass, posterior, 721, 721f
resection of, 721724
azygos vein injury with, 724, 724f
cerebrospinal uid leak with, 722
chylothorax with, 723
esophageal injury with, 723
spinal cord injury with, 721722
steps in, 721
sympathetic nerve injury with, 722
thoracic aortic injury with, 723
thoracic nerve root injury with, 722723
vagus nerve injury with, 723724
Mediastinitis, 717718
Mediastinoscopy, 663666
bleeding with, 664665
inappropriate patient selection for, 664
instruments for, 664, 665f
patient selection for, 663, 664, 664f
pneumothorax with, 665666
positioning for, 663, 664f
steps in, 663
Mediastinotomy, anterior, 666668
airway loss with, 666667
anesthesia for, 666667
bleeding with, 667
incision for, 667, 667f
indications for, 666, 666f
intraoperative pathology for, 668
pneumothorax with, 667668, 668f
Mediastinum
chest tube placement in, 140141
packing of, 665
Medical records
alteration of, 2526
completeness of, 25
for informed consent, 24
 892 INDEX

Medical records (Continued)
requests for, 26
review of, 26
Medications, preoperative, 5658
Melanoma
amputation for, 499
isolated limb perfusion in, 497499
indication for, 497
melphalan for, 497, 498499, 498b
pump oxygenator for, 498
steps in, 497
tourniquet application for, 499
toxic effects with, 498499
vessel dissection for, 498
Melphalan
for isolated limb perfusion, 497, 498499,
498b
nerve injury with, 498, 498b
toxicities of, 498499, 498b
Mental status, posttraumatic, 764
Meperidine, 29t, 50t
seizure with, 49
Mercedes-Benz sign, 518, 519f
Mesenteric artery
injury to
pancreaticoduodenectomy and, 370
rectal resection and, 275277, 277f
in neuroblastoma resection, 864865, 865f
thrombosis of, laparoscopic Nissen
fundoplication and, 184
Mesenteric vein
inferior, injury to, 376
superior, injury to, 368369, 369f, 381
Mesentery
bleeding of, laparoscopic gastric bypass and,
204205, 208209, 219
dbridement of, in colectomy, 269, 269f
division of, in laparoscopic gastric bypass,
204205, 204f
hematoma of, jejunostomy and, 156
injury to
enterectomy and, 239, 239f, 243244,
244f
Ladd procedure and, 823
transillumination of, in enterectomy, 239,
239f
Mesh
in damage control surgery, 806807
in epigastric hernia repair, 523525, 524f
525f, 526f
in incisional hernia repair, 533534, 534f,
539541
in inguinal hernia repair, 503506, 504f,
505f, 506f, 519520, 520f, 521f
in splenorrhaphy, 791792, 793f
in umbilical hernia repair, 523525, 524f
525f, 526f
Metabolic acidosis, damage control surgery
steps for, 804
Metal allergy, after pectus excavatum repair,
847
Metastasis
adrenal gland, 423f
pulmonary, 495
Methemoglobinemia, 5253
Methylene blue testing, 354
Microbracing, 19, 20f
Microcalcications, breast, 450
Midazolam, 50t
hypotension with, 60
Middle colic artery, gastrectomy-related injury
to, 224, 224f
Mitral stenosis, 5960
Model for end-stage liver disease (MELD)
score, 3536
Monoethylglycinexylidide test, 355
Morbidity and mortality conference, 2, 45
Morphine, 29t, 50t
Movement simplication, 20
Multiple endocrine neoplasia, 45t, 418419
Murphys Law, 24
Muscle, melphalan-induced injury to, 498
499, 498b
Muscle-splitting appendectomy incision, 70,
71f
Myasthenic crisis, thymectomy and, 720721
Myocardial infarction
infrainguinal revascularization and, 627628
postoperative, 3032
Myotomy, for laparoscopic esophagomyotomy
with Dor fundoplication, 190193, 191f,
192f, 193f
N Nissen fundoplication
Naloxone, 50t, 52
Nasogastric tube
for laparoscopic Nissen fundoplication,
180181, 181f
stapling of, in laparoscopic gastric bypass,
210211
in trauma, 766
Nausea
in isolated limb perfusion of melphalan, 499
postoperative, 6364, 64b, 64t
Neck. See also Neck injury
anatomy of, 809, 810f
hematoma of, 404
Neck injury, 809816
anatomy of, 809, 810f
epidemiology of, 809, 810t
management of, 809812
airway failure with, 810811, 810f
angiography for, 813814, 814b
balloon tamponade for, 811, 811f
brain computed tomography for, 815
cervical collar interference with, 811812
color ow Doppler for, 814, 814b
computed tomography for, 814815
cricothyroidotomy for, 810811
esophageal studies for, 815, 815f
examination for, 812816, 812b, 813f
hemorrhage with, 811
laryngotracheal studies for, 815816
patient selection for, 812
radiography for, 812, 814f
Necrosis
gastric, splenctomy and, 576
omental, Graham patch repair and, 161
162, 162f
pancreatic. See Pancreatic necrosis
skin, component separation and, 548
skin ap, mastectomy and, 476477, 476f
stomal
colostomy and, 295296
ileostomy and, 249, 249f
Necrotizing enterocolitis, 824, 824f
Needle
for breast biopsy, 440
intraosseous placement of, 765
for paracentesis, 144
SuturTek, 89, 89f
Veress, 97, 98, 98f, 99, 198
retroperitoneal vascular injury with, 99
100, 100f
Needlestick injury, 89, 89f
Nelsons syndrome, 423
Nerve blocks, 5356
ankle, 53t, 5556, 57f
femoral nerve, inadvertent, 54
nger, 53t, 5455, 55f
ilioinguinal nerve, 53, 54f
Nerve blocks (Continued)
median nerve, 53t, 55, 56f
needle misposition with, 56
radial nerve, 53t, 55
ulnar nerve, 53t, 55, 56f
Nerve injury. See at specic nerves
Nerve roots, injury to
chest wall resection and, 711712
mediastinal mass resection and, 722723
Nervi erigentes, injury to, 833
Neuroblastoma, 863865
biopsy for, 864
resection for, 863865
steps in, 864
vascular injury with, 864865, 865f
vs. Wilms tumor, 864, 864f
Neurologic injury, trauma-related, 761
Nissen closure, in gastrectomy, 225, 226f
bowel obstruction after, 824
laparoscopic, 175184
aberrant left hepatic artery injury with,
175176
aortic injury with, 182, 182f
bougie insertion for, 180181
cardiac injury with, 184
celiac artery thrombosis with, 184
crus closure breakdown with, 183
dysphagia with, 182183
esophageal hiatus closure for, 182183,
182f
esophageal injury with, 176177, 178f
esophageal perforation with, 180181,
181f
gas bloat syndrome with, 180, 180f
gastric injury with, 180, 180f
gastric perforation with, 180181
gastric ulceration with, 183184
gastric vessel ligation for, 179180, 179f,
180f
gastroesophageal junction dissection for,
176178, 177f
harmonic scalpel for, 180, 180f
hepatic hematoma with, 184
hepatogastric ligament division for, 175
176, 176f
herniation of, 183
indications for, 175
intraluminal suture placement with, 183
nasogastric tube insertion for, 180181,
181f
pancreatitis after, 184
pneumomediastinum with, 177178
pneumopericardium with, 177178
pneumothorax with, 177178, 178f
slipped, 183
splenic injury with, 179, 179f
steps in, 175
superior mesenteric artery thrombosis
with, 184
sutures for, 183
trocar insertion injury with, 175
vagus nerve injury with, 176, 177f
Nonalcoholic steatotic hepatitis, laparoscopic
gastric bypass and, 201202
NPO guidelines, 63
Nutrition
assessment of, 3839, 38f
deciency of, after gastrectomy, 233
O
Obesity
abdominal perineal resection and, 297, 297f
component separation procedure and, 548,
549f550f

Obesity (Continued) Pancreatic injury (Continued)
denition of, 197 management of, 779784
gastric bypass for. See Gastric bypass, delayed, 780
laparoscopic diagnosis in, 779780
Objectives, operative, in technical skills duct identication for, 782783
instruction, 1516 exposure for, 780782, 780f, 781f, 783f
Obstructive sleep apnea, 33, 34f stula formation with, 782783
postoperative management of, 6162 hemodynamic instability with, 782
Omental patch, for perforated duodenal ulcer. missed injury with, 781, 782f
See Graham patch repair principles of, 783
Ondansetron, 6364, 64t replaced right hepatic injury with, 781
One Minute Manager, The, 21 782
Opioids, 2829, 29t stabilization in, 779780
vasodilatory effects of, 52 steps in, 779
Orchitis, ischemic, inguinal hernia repair and, splenectomy and, 793
502 Pancreatic necrosis, 385389, 386f
Osmotic diuretics, in traumatic brain injury, management of, 385389
788 ascites with, 388389
Osteoporosis, in Cushings syndrome, 426 closure for, 389
Oxycodone, 29t dbridement for, 386, 387388
Oxygen tension, transcutaneous, 613 delayed dbridement for, 386387
drainage for, 388389, 388f
endocrine insufciency with, 387388
P exocrine insufciency with, 387388
Pacemaker, perioperative management of, 60 exposure for, 387
61 incision for, 386387, 387f, 389
Pain limited drainage with, 389
arteriovenous access and, 638 middle colic vessel ligation for, 387
incisional hernia repair and, 541542 pancreaticocutaneous stula with, 388
inguinal hernia repair and, 505 pleural effusion with, 388389
low threshold for, 2829, 28t, 29t vascular injury with, 387
mastectomy and, 479 sterile, 386387
stapled hemorrhoidectomy and, 311, 312 Pancreatic pseudocyst, drainage for
VATS lobectomy and, 672673 anastomotic leak with, 384
Pancoasts tumor, 712714, 713f anterior gastrotomy bleeding with, 383384
Pancreas cyst mislocation with, 384
cyst of. See Pancreatic cyst endoscopic, 383384
injury to. See Pancreatic injury external, 384385
necrosis of. See Pancreatic necrosis mesocolon vessel injury with, 384
pseudocyst of. See Pancreatic pseudocyst Roux-en-Y cystjejunostomy for, 384
Pancreatectomy, distal, 375378 sump drains for, 385
adrenal vein injury with, 376377 Pancreaticocutaneous stula, 388
bleeding with, 375376, 377 Pancreaticoduodenectomy, 367372
exposure for, 375376 common bile duct transection for, 368
incision for, 375 delayed gastric emptying after, 371372
indications for, 375 foregut ischemia with, 371, 371f, 372f
inferior mesenteric vein injury with, 376 hemorrhage with, 372
leak/stula with, 377378 indications for, 367
left renal vein injury with, 376377, 376f Kochers maneuver for, 368
medial reection for, 376377, 376f morbidity with, 367, 372
middle colic vein injury with, 376 mortality from, 367, 372
pancreatic tail dissection for, 376 pancreatic stula after, 367, 370371
parenchymal division for, 377378 pancreaticojejunostomy for, 370371
splenic mobilization with, 376 portal vein dissection for, 369370, 370f
splenic vessel ligation for, 377, 377f portal vein injury with, 369370
steps in, 375 pseudoaneurysm with, 371, 371f, 372f
Pancreatic cyst, drainage of, 383385 pylorus-sparing, 367
bleeding with, 383384 steps in, 367368
endoscopic, 383384 superior mesenteric artery in, 368369,
external, 384385 369f, 370
Pancreatic duct superior mesenteric artery injury with, 370
aspiration of, 380, 380f Pancreaticojejunostomy, 370371
dilation of, 379, 380f lateral, 379382
drainage of. See Pancreaticojejunostomy, anastomosis for, 381, 382f
lateral aspiration for, 380, 380f
identication of, 782783, 783f drainage for, 381, 381f
incision of, 381, 381f exploration for, 379380
palpation of, 380 exposure for, 380
Pancreatic stula, 782783 inadequate exposure for, 380
pancreatectomy and, 377378 indications for, 379
pancreaticoduodenectomy and, 367, 370 insufcient decompression for, 381, 381f
371 Kocher maneuver for, 380
Pancreatic injury leak with, 382
adrenalectomy and, 429 pancreatic duct identication for, 380
damage control surgery for, 802 381
laparoscopic splenectomy and, 578 Roux-en-Y limb orientation for, 381
INDEX 893
Pancreaticojejunostomy (Continued)
steps in, 379
superior mesenteric vein injury with, 381
unexpected ndings on, 379380
Pancreatitis, after laparoscopic Nissen
fundoplication, 184
Papilloma, of breast, 446447, 447f
Paracentesis, 143146
ascites leak with, 146
bleeding with, 145
uid and electrolyte imbalance with, 145
146
uid nonlocalization in, 143144
indications for, 143
infection with, 145
needle selection for, 144
organ perforation with, 144, 144f
procedure for, 143146, 144f
steps in, 143
Paraesophageal hernia, laparoscopic
esophagomyotomy and, 189, 189f
Parallax, 1819, 18f, 19f
Paralysis, 58
Paraplegia, tracheal resection and, 750
Parathyroid glands
adenoma of, 410, 411, 411f
anatomy of, 409410, 409f
autotransplantation of, 401, 413, 417419
biopsy of, 412
cancer of, 419
capsule of, 412
cryopreservation of, 418
ectopic, 409410
hyperplastic, 410, 412413
iatrogenic injury to, 411
normal appearance of, 410
number of, 410
supernumerary, 412413
surgery on, 407419. See also
Parathyroidectomy
vs. thymic tissue, 410
in thyroid surgery, 398, 398f, 400401,
401t
Parathyroid hormone
intraoperative monitoring of, 416417
pharmacologic, 401
Parathyroid surgery, 407419, 408f. See also
Parathyroidectomy
Parathyroidectomy, 408413, 408f
biopsy for, 412
cancer discovery with, 419
capsule disruption with, 412
closure for, 413
cryopreserved normal gland with, 418
directed, 413417
extension of, 417
false-positive parathyroid hormone level
with, 416417
gamma probe for, 416
imaging for, 414416, 414f, 415f
incision for, 417
indications for, 413
parathyroid hormone monitoring for,
416417
sestamibi scan for, 414415, 415f
steps in, 414
ultrasonography for, 414, 414f, 416
dissection for, 409412, 410f, 411f
failure of, 409411
in genetic disease, 418419
hypocalcemia after, 413
inaccurate closure for, 413
incision for, 409
indications for, 408
multigland disease and, 410
normal gland injury with, 411
 894 INDEX
Parathyroidectomy (Continued)
recurrent laryngeal nerve injury with, 409f,
411412
steps in, 409
subtotal, 412413
supernumerary glands and, 412413
total, 413
ultrasonography for, 410
Paravesical abscess, inguinal hernia repair and,
507
Paresthesia, axillary artery cannulation and,
131, 133f, 134
Parkinson disease, 59
Patent foramen ovale, 701702, 702f
Patient-surgeon communication, 2324
Pectoral fascia preservation, in total
mastectomy, 479, 480
Pectoral nerves, in mastectomy, 484, 484f
Pectoralis muscle, in mastectomy, 484, 484f
Pectus excavatum, 839847
repair of, 839847
indications for, 839
minimally invasive (Nuss), 842847
arrhythmias after, 847
bar and lateral stabilizers for, 845846,
845f, 846f
bar displacement with, 845846
cardiac injury with, 845
cosmetic result of, 847
epidural catheter placement for, 843,
843f
infection after, 847
introducer and bar for, 843845, 843f
metal allergy after, 847
pericardial injury with, 843, 845
pleural effusion after, 846
pneumothorax with, 846
scoliosis after, 847
seroma after, 846
stabilizer misxation with, 846
steps in, 842843
thoracic outlet syndrome after, 847
transient Horners syndrome with, 843
open (modied Ravitch), 839842
asphyxiating thoracic dystrophy after,
842
cardiac injury with, 842
costochondral junction damage with,
840841
deformity recurrence after, 842
infection after, 842
intercostal vessel injury with, 841842
internal mammary vessel injury with,
841842
perichondral damage with, 840
pleural dissection for, 842
pneumothorax with, 842, 842f
seroma after, 842
steps in, 839840
strut placement for, 841842, 841f
subperichondral resection for, 840
841, 840f
Pelvic binder, 768, 768f
Pelvic injury, 767768
binder for, 768, 768f
CT scan with IV contrast with, 768
hemorrhage with, 767768, 768f
Peptic ulcer disease
duodenal, perforation with
enlargement of, 160
after Graham patch repair, 164, 164b
nonoperative treatment of, 159, 160b
operative treatment of. See Graham patch
repair
sealed, 159, 160
Helicobacter pylori infection and, 163164
Performance
knowledge-based, 3
rule-based, 3
skill-based, 3
Pericardial defect, pneumonectomy and, 696,
696f
Pericardial injury, pectus excavatum repair
and, 843, 845
Pericardial tamponade, central vein
catheterization and, 115116, 117f
Perineal stula, 828, 828f, 828t
Perineal resection, abdominal. See Abdominal
perineal resection
Perineum, reconstruction of, 830
Peripheral motor neuropathy, 5859
Peritoneal cavity, identication of, for
laparotomy, 7374, 73f, 74f
Peritoneum, tear in, aortobifemoral bypass
and, 600601
Peritonitis
fecal, aortobifemoral bypass and, 603
laparoscopic Nissen fundoplication and,
180, 180f
Peroneal nerve, adrenalectomy-related injury
to, 425426
Peutz-Jeghers syndrome, 44t
Pfannenstiel incision, 70, 72f
Phantom breast syndrome, 485
Pheochromocytoma, 423
Phrenic artery, in right hepatectomy, 333
Phrenic nerve, injury to
supraclavicular lymph node biopsy and,
583584
thoracic trauma and, 775
thymectomy and, 719
VATS lobectomy and, 673674
Phrenic vein, 431, 431f
in right hepatectomy, 333
vagotomy-related injury to, 168
Platelet dysfunction, 39
Platypneaorthodeoxia syndrome, 701702,
702f
Pleura, adrenalectomy-related injury to, 430
Pleural effusion
esophagectomy and, 733734
pancreatic drainage and, 388389
pectus excavatum repair and, 846
trisectionectomy and, 347348
Pneumatosis intestinalis, 824, 824f
Pneumomediastinum, laparoscopic Nissen
fundoplication and, 177178
Pneumonectomy, 693702
airway compression after, 701, 701f,
702f
arrhythmias after, 699700
bronchopleural stula with, 698699, 698f,
699f
bronchus closure for, 698699, 698f
cardiac herniation with, 695696, 696f
chylothorax with, 693694
empyema with, 698699, 698f, 699f
esophagopleural stula with, 695
hilar mobilization for, 695696, 696f
indications for, 693
mediastinal lymphadenectomy for, 693
695, 694f
pericardial defect with, 696, 696f
peripheral tumor embolus with, 696,
697f
platypneaorthodeoxia syndrome after,
701702, 702f
pulmonary artery embolism/thrombosis
with, 696698
pulmonary artery ligation for, 696698
pulmonary edema after, 700701, 700f
pulmonary vein ligation for, 696
Pneumonectomy (Continued)
recurrent laryngeal nerve injury with, 694
695, 695f
steps in, 693
Pneumonia
esophagectomy and, 734, 736
infrainguinal revascularization and, 628
Pneumopericardium, laparoscopic Nissen
fundoplication and, 177178
Pneumoperitoneum
for gastric bypass, 198201
incomplete evacuation of, 868
Pneumothorax
anterior mediastinotomy and, 667668,
668f
central vein catheterization and, 113114,
114f
chest tube insertion and, 140, 141
congenital diaphragmatic hernia repair and,
857858
laparoscopic hepatectomy and, 362
laparoscopic Nissen fundoplication and,
177178, 178f
laparoscopic surgery and, 101102
mastectomy and, 485
mediastinoscopy and, 665666
pectus excavatum repair and, 842, 842f,
846
tension, trauma-related, 761762
thymectomy and, 720
ultrasound image-guided breast biopsy and,
444
vagotomy and, 172
Polytetrauoroethylene graft, vs. Dacron graft,
597598
Portal vein, 84, 86f
caudate, hepatectomy-related injury to, 341,
342f
cholangiocarcinoma of, 393, 393f
injury to
biliary resection and, 393394
laparotomy and, 8485
left hepatectomy and, 341, 342f
liver resection and, 327
pancreaticoduodenectomy and, 369370,
370f
right hepatectomy and, 334335, 335f,
336f
trisectionectomy and, 348349
posterior, right hepatectomyrelated injury
to, 335f, 336f
right, right hepatectomyrelated division of,
335f
thrombosis of, 580
Portal vein embolization, in trisectionectomy,
356
Positive-pressure ventilation, in trauma, 761
762
Posterior sagittal anorectoplasty, 831832,
832f. See also Anoplasty
steps in, 831
urethral diverticulum with, 831
Postgastrectomy syndromes, 229233
Postpneumonectomy syndrome, 701, 701f,
702f
Practice, 1718
deliberate, 67
independent, 1718
Pregnancy
bleeding during, 62
intubation in, 62
Preoperative pitfalls, 2745
in advanced liver disease screening, 3436,
35t
in bleeding risk assessment, 3942, 40t,
41f

Preoperative pitfalls (Continued)
in cardiac risk assessment, 3033, 31t, 32b,
32t
in endocrine assessment, 4243, 43b
in family history documentation, 4345,
44t45t
in hypercoagulable state assessment, 39,
4142, 42t
in infection risk assessment, 3738, 37t
in neurologic evaluation, 2730, 28f, 28t,
29b, 29t, 30b, 30f
in nutritional assessment, 3839, 38f
in pulmonary risk assessment, 3334, 34f,
35f
in renal assessment, 3637, 36b
Pringle maneuver
in hepatectomyrelated bleeding, 337
in trisectionectomy, 348, 351
Progesterone, in pregnancy, 62
Promethazine, 6364, 64t
Propofol, 51
hypotension with, 60
Prothrombin deciency, 40t
Pseudoachalasia, 187
Pseudoaneurysm
abdominal aortic aneurysm repair and, 609
610
arteriovenous access and, 640, 640f
endovascular intervention and, 652
pancreaticoduodenectomy and, 371, 371f,
372f
radial artery, cannulation-related, 130, 130f
Puestow procedure. See
Pancreaticojejunostomy, lateral
Pulmonary artery
embolism of, pneumonectomy and, 696
698
reconstruction of, in bronchial and vascular
sleeve lobectomy, 690691, 690f, 691f
rupture of, catheterization and, 124127,
125f, 126f
thrombosis of, pneumonectomy and, 696
698
Pulmonary artery catheterization, 121127
arrhythmia with, 123
catheter coiling/knotting with, 123124,
124f
catheter embolism with, 127
external jugular vein for, 122
femoral vein for, 122
indications for, 121
internal jugular vein for, 122
misplacement of, 127
procedure for, 122123, 122f
pulmonary artery rupture with, 124127,
125f, 126f
pulmonary infarction with, 127
pulmonary valve injury with, 127
steps in, 121122
subclavian vein for, 122
thrombocytopenia with, 127
tricuspid valve injury with, 127
ventricular perforation with, 127
Pulmonary edema
chest tube insertion and, 141142
pneumonectomy and, 700701, 700f
Pulmonary embolism, 39, 4142, 42t
component separation procedure and, 568
Pulmonary infarction, pulmonary artery
catheterization and, 127
Pulmonary sequestration, in congenital
diaphragmatic hernia repair, 858, 858f
Pulmonary shunt, laparoscopic surgery and,
102
Pulmonary valve, catheterization-related injury
to, 127
Pulse oximetry, in sentinel node biopsy, 469
Pursestring suture
in jejunostomy feeding tube, 156
in stapled hemorrhoidectomy, 311312,
311f
Pyloromyotomy, 871874
care after, 874
duodenum retraction for, 872
failed, 874
feeding after, 874
incomplete, 873
indications for, 871
laparoscopic, 871
mucosal pyloric perforation with, 872873
open, 871
preoperative management in, 871872
pylorus incision for, 872873, 873f
steps in, 871
stomach perforation/laceration with, 872
stomach retraction for, 872
vomiting after, 873
wound complications of, 874
Pyloroplasty, 167172
anastomotic leak with, 171172
closure for, 171172, 171f
Finney, 167, 168, 171, 171f
Heineke-Mikulicz, 167168, 170f, 171
inadequate drainage after, 170171
inadequate/incomplete Kocher maneuver
with, 172
indications for, 167
Jaboulay, 167, 168, 171
steps in, 167168
Pylorus
identication of, 784
perforation of, 872873, 873f
Pyoderma gangrenosum, 254
Q Rewarming, in damage control surgery, 803
Quest, Don, 5
Queuing, 8
R fracture of, 776777
Radial artery, cannulation of, 129131, 130f
infection with, 129130
ischemia with, 131
pseudoaneurysm with, 130, 130f
thrombosis with, 129
Radial nerve block, 53t, 55
Radial scar, 450451, 451f
Radiation therapy, in soft tissue sarcoma,
492493, 494f, 495f
Radiography
in breast biopsy, 442, 458
in damage control surgery, 800, 804
in neck injury, 812, 814f
in partial mastectomy, 461f, 462
postlaparotomy, 94
Ramsey Sedation Score, 29, 29b
Rectovaginal stula, hemorrhoidectomy and,
311, 312
Rectovesical stula, 831, 832f
Rectum
See also Posterior sagittal anorectoplasty
anatomy of, 278279
congenital malformation of. See Anorectal
malformations
dilatation of, in pediatric colostomy, 831
dissection of, in anoplasty, 829
ischemia of, in pediatric colostomy, 830
831
resection of. See Abdominal perineal
resection; Low anterior resection
Rectus abdominis muscle, denervation of, 560
INDEX 895
Recurrent laryngeal nerve
anatomy of, 735f
injury to
esophagectomy and, 734735
parathyroidectomy and, 411412
pneumonectomy and, 694695
thymectomy and, 719720, 720f
thyroid surgery and, 401402, 401t
tracheal resection and, 743745, 744f
VATS lobectomy and, 682683
in thyroid surgery, 398f, 399f, 402
Refusal of care, documentation of, 24
Renal artery, reimplantation of, 610
Renal failure, 3637, 36b
Renal vein
injury to
adrenalectomy and, 426, 431
pancreatectomy and, 376377
pancreaticoduodenectomy and, 368
retroaortic, 610
Respiratory depression, 5152
Respiratory failure
esophagectomy and, 734
infrainguinal revascularization and, 628
Respiratory insufciency
component separation procedure and, 566
567
VATS lobectomy and, 673674
RET gene, 418419
Retroperitoneal bleeding, femoral artery
cannulation and, 131, 132f
Retroperitoneal hematoma
damage control surgery and, 801802
laparoscopic splenectomy and, 579
laparoscopic surgery and, 99100, 100f
Revascularization, infrainguinal. See
Infrainguinal revascularization
Reverse Trendelenburg position, cardiac
output with, 101
804
Rhabdomyolysis, laparoscopic surgery and,
102103
Rib(s)
resection of
in open posterior adrenalectomy, 430
in subphrenic abscess treatment, 92, 93f
Richmond Agitation-Sedation Scale, 29, 29b
Richters hernia, in laparoscopic gastric bypass,
220
Right triangular ligaments, division of, 331
333, 332f
Rouvieres sulcus, in laparoscopic
cholecystectomy, 321, 321f
Roux-en-Y cystjejunostomy, 384
Roux-en-Y gastric bypass surgery. See Gastric
bypass, laparoscopic
Roux stasis syndrome, after gastrectomy, 231,
231f
S
Sagittal anorectoplasty, posterior, 831832,
832f. See also Anoplasty
steps in, 831
urethral diverticulum with, 831
Sandwich technique, for feedback, 21
Saphenofemoral junction, 644f
misidentication of, 645
Saphenous nerve, injury to
infrainguinal revascularization and, 617
stab avulsion and, 647
vein stripping and, 643
Sarcoma. See Soft tissue sarcoma
Satinsky clamp, 84, 85f
 896 INDEX
Schumacher, E. F., 8
Scoliosis, pectus excavatum repair and, 847
Scopolamine, 6364, 64t
Sedation. See also Anesthesia
Ramsey Sedation Scale for, 29, 29b
Richmond Agitation-Sedation Scale for, 29,
29b
Seizures, 4950
Seldinger technique, for central vein
catheterization, 110
Sentinel lymph node biopsy, 468471
allergic reaction with, 469
contraindications to, 468469
dissection for, 469470, 469f, 470f
failure of, 470, 471
false-negative node with, 470471
indications for, 468
infection after, 471
isosulfan blue dye for, 468, 469, 469f, 470,
470f
lymphedema after, 469470
palpable nodes in, 471
pulse oximeter reading with, 469
seroma after, 469470
steps in, 469
Sephralm (sodium hyaluronate
carboxymethylcellulose), 95
Seroma
arteriovenous access and, 639640, 640f
axillary dissection and, 468
component separation procedure and, 554,
556557, 567
epigastric hernia repair and, 526527
incisional hernia repair and, 534, 534f
infrainguinal revascularization and, 625
inguinal hernia repair and, 506, 506f
laparoscopic incisional hernia repair and,
541
pectus excavatum repair and, 842, 846
sentinel lymph node biopsy and, 469470
total mastectomy and, 477479
umbilical hernia repair and, 526527
Sestamibi scan, in parathyroidectomy, 414
415, 415f
Sexual dysfunction, after low anterior
resection, 282283
Shock
adrenal insufciency and, 43
cardiogenic, 770
neurogenic, 770
trauma-related, 763, 769770, 770f
Short bowel syndrome, after enterectomy,
244245
Shunt
in carotid endarterectomy, 591, 591f
in damage control surgery, 801802
Side-biting clamp, for venous hemorrhage, 84,
85f
Skill acquisition, 68. See also Technical skills
instruction
competency and, 7
Fitts and Posner model of, 68, 6f, 7f
information overload in, 8
queuing in, 8
Skin
laser burns of, 646
melphalan-related injury to, 498499, 498b
necrosis of
epigastric hernia repair and, 528
umbilical hernia repair and, 528
stoma-related breakdown of, 249
Small intestine
injury to
adrenalectomy and, 428
component separation procedure and,
557
Small intestine (Continued)
inguinal hernia repair and, 506
jejunostomy and, 156
laparoscopic gastric bypass and, 203204
laparoscopic incisional hernia repair and,
542, 542f
laparotomy and, 7475, 75f, 76f
percutaneous gastrostomy tube placement
and, 151152, 152f
right colectomy and, 259260
ischemia of
cholecystectomy and, 323324
identication of, 238
laparoscopic gastric bypass and, 204, 209
milking of, 238, 238f
obstruction of
aortobifemoral bypass and, 603604
congenital, 823824, 823f
enterectomy and, 245
infectious, in neonate, 824, 824f
laparotomy-related, 75, 9495
mechanical, in children, 824825
recurrent, in children, 825
resection of. See Enterectomy
Sodium hyaluronate carboxymethylcellulose,
95
Sodium thiopental, hypotension with, 60
Soft tissue sarcoma, 489496
biopsy of, 490491
computed tomography of, 491492, 491f
diagnosis of, 489, 495
imaging of, 491492, 491f, 492f
limb-sparing surgery for, 492
magnetic resonance imaging of, 491492,
491f, 492f
overaggressive therapy for, 493495, 494f
pseudocapsule of, 493
radiation therapy for, 492493, 494f, 495f
recurrence of, 492494, 495
staging of, 489490, 490f, 490t
surgical margins in, 493
Spermatic vessel injury, inguinal hernia repair
and, 867
Spinal cord injury
mediastinal mass resection and, 721722
missed diagnosis of, 764
Spine, trauma-related manipulation of, 761
Splanchnic circulation, laparoscopic surgery
effects on, 130
Spleen
accessory, 573, 574f
vs. adrenal tumor, 422f
injury to. See Splenic injury
mobilization of, 7981, 81f
Splenectomy
for iatrogenic injury, 79
laparoscopic, 571580
abdominal exploration for, 573, 574f
abscess after, 579
accessory spleens in, 573, 574f
bleeding with, 574, 575, 576578
capsular bleeding with, 574
colonic injury with, 573574
contraindications to, 571572
diaphragmatic injury with, 574575
gastric perforation with, 576
hanging spleen technique in, 572
hilar bleeding with, 576578
immunization before, 572, 580
indications for, 571
infection after, 580
instrumentation for, 572
irrigation and hemostasis for, 579
lateral attachment incisions for, 574575,
575f
lower pole vessel division for, 575
Splenectomy (Continued)
pancreatic injury with, 578
portal vein thrombosis after, 580
positioning for, 572, 572f
retroperitoneal hematoma after, 579
short gastrics division for, 575576, 576f
splenic mobilization for, 573574
splenic vein thrombosis after, 580
splenic vessel dissection and ligation for,
576578, 577f
splenosis after, 578579
steps in, 572
thrombocytopenia after, 573
thrombosis after, 580
tissue removal for, 578579, 579f
trocar insertion for, 572573, 573f
trocar removal for, 579
open
gastric injury with, 793794
infection after, 794
pancreatic injury with, 793
partial, 791, 792f
Splenic artery
angioembolization of, 794
dissection and ligation of, 576578, 577f
Splenic exure, retraction of, 8081, 82f
Splenic injury
adrenalectomy and, 429430
aortobifemoral bypass and, 601
colectomy and, 268269, 268f
computed tomography in, 794, 796f
esophagectomy and, 730
laparoscopic esophagomyotomy with Dor
fundoplication and, 194
laparoscopic Nissen fundoplication and,
179, 179f
laparotomy and, 7881, 79f
left hepatectomy and, 344
management of, 791797. See also
Splenectomy
nonoperative, 794797, 794b
algorithm for, 796f
angioembolization for, 795, 796f
computed tomography for, 795797,
796f
criteria for, 794795, 795b
follow-up for, 795
results of, 795, 797
splenorrhaphy for
absorbable mesh wrap in, 791792,
793f
argon beam coagulator in, 791, 793f
brin glue in, 792
mobilization/exposure for, 791, 792f
pancreatectomy and, 376
rectal resection and, 278, 278f
vagotomy and, 169
Splenic vein
dissection and ligation of, 576578, 577f
pancreatectomy-related injury to, 377
thrombosis of, 580
Splenorrhaphy. See also Splenectomy
absorbable mesh wrap for, 791792, 793f
argon beam coagulator for, 791, 793f
brin glue for, 792
mobilization/exposure for, 791, 792f
Splenosis, after splenectomy, 578579
Sponge sticks, for venous hemorrhage, 84,
85f
Spontaneous abortion, 6263
Stamm gastrostomy feeding tube. See
Gastrostomy feeding tube, open
placement of, Stamm
Stapler/stapling
across nasogastric tube, in laparoscopic
gastric bypass, 210211

Stapler/stapling (Continued)
bleeding from, in laparoscopic gastric
bypass, 211
bowel perforation by, in laparoscopic gastric
bypass, 206207
for hemorrhoidectomy. See
Hemorrhoidectomy, stapled
leak from, in laparoscopic gastric bypass,
212
misring of
in enterectomy, 239240
in laparoscopic gastric bypass, 206, 211,
215
in partial adrenalectomy, 432, 432f
Stellate ganglion, thyroid surgeryrelated
injury to, 403
Stenosis
anal, hemorrhoidectomy and, 308
aortic, 5960
celiac artery, pancreaticoduodenectomy and,
371
duodenal, Graham patch repair and, 160
161
enteroenterostomy, laparoscopic gastric
bypass and, 207208
esophageal, atresia repair and, 853854,
854f
gastrojejunostomy, laparoscopic gastric
bypass and, 216217
mitral, 5960
Roux-en-Y limb, in laparoscopic gastric
bypass, 219
stomal
colostomy and, 297, 297f
ileostomy and, 249, 249f
Stent, carotid artery, 593594
Sternocleidomastoid muscle, parathyroid gland
transfer to, 401, 417419
Sternotomy, 717718
infection and, 714715
Stoma. See Colostomy; Ileostomy
Stomach
conduit of, for esophagectomy, 731732,
732f
feeding tube in. See Gastrostomy feeding
tube placement
injury to
adrenalectomy and, 427
gastrostomy and, 149
laparoscopic esophagomyotomy with Dor
fundoplication and, 190, 190f
laparoscopic gastric bypass and, 213
laparoscopic Nissen fundoplication and,
180181, 180f
left hepatectomy and, 341
pyloromyotomy and, 872
splenectomy and, 576, 793794
surgical bypass of. See Gastric bypass,
laparoscopic
tumor of, vs. adrenal tumor, 422f
ulcer of, after laparoscopic Nissen
fundoplication, 183184
volvulus of, left hepatectomy and, 342343
Stricture
anal, hemorrhoidectomy and, 311, 312
anastomotic
enterectomy and, 241242, 243f, 244f
gastrectomy and, 230231
rectal resection and, 285286
biliary, resection and, 394
Stroke
carotid endarterectomy and, 590591
patient history of, 5859
Subclavian vein
catheterization of, 109110, 111f, 112
arterial puncture with, 112113
Subclavian vein (Continued)
for pulmonary artery catheterization, 122
stenosis of, in arteriovenous access
procedures, 633635, 634f, 635f
Subcostal nerve, adrenalectomy-related injury
to, 430
Subcutaneous emphysema, laparoscopic gastric
bypass and, 199200
Subcutaneous tissue, chest tube placement in,
140
Subdural hematoma, in traumatic brain injury,
788789, 788f
Subfascial endoscopic perforator surgery, 647
648
Subroutines, 1213
Succinylcholine, 5859, 58b
Supercial peroneal nerve, infrainguinal
revascularizationrelated injury to, 616
Supercial venous insufciency, 643. See also
Varicose veins
Superior laryngeal nerve, thyroid surgery
related injury to, 402403
Superior mesenteric artery
in neuroblastoma resection, 864865,
865f
thrombosis of, laparoscopic Nissen
fundoplication and, 184
Supraclavicular lymph node biopsy, 583584
Surgical assistants, disclosure of, 24
Sutures
in enterectomy anastomosis, 240, 241f
in Graham patch repair, 160, 161f, 162
163, 162f, 163f
in laparoscopic Nissen fundoplication, 183
in laparotomy closure, 87, 87f, 8889, 88f
in mastectomy, 482, 484
in open gastrostomy tube placement, 148
150
pursestring
in hemorrhoidectomy, 311312, 311f
in jejunostomy feeding tube, 156
SuturTek needle, 89, 89f
Sympathetic nerves, injury to
mediastinal mass resection and, 722
thyroid surgery and, 403
T Thrombophlebitis, greater saphenous vein
Technical skills instruction, 1122
feedback for, 2122
intraoperative, 1721
bracing and, 19, 20f
parallax and, 1819, 18f, 19f
simplifying movement and, 20
visualization and, 2021
postoperative, 2122
preoperative, 1317
equipment familiarization in, 1617
goals and objectives denition in, 1516
learning needs assessment in, 1315
principles of, 1213
TENDS pneumonic, 21
Tensor fascia lata aps, in abdominal wall
reconstruction, 560563, 564f, 565f
Testes, inguinal hernia repairrelated injury to,
502
Tetracaine, 50t
Thoracic aorta, mediastinal mass resection
related injury to, 723
Thoracic duct
anatomy of, 694, 694f
injury to. See also Chylothorax
central vein catheterization and, 114115
thyroid surgery and, 403
vagotomy and, 169
ligation of, 737, 738f
INDEX 897
Thoracic dystrophy, asphyxiating, pectus
excavatum repair and, 842
Thoracic inlet, anatomy of, 712, 713f
Thoracic nerve root, mediastinal mass
resectionrelated injury to, 722723
Thoracic outlet syndrome, pectus excavatum
repair and, 847
Thoracic trauma, 773777
abdominal injury in, 775
diaphragm injury in, 775, 775f
hemothorax in, 774, 774f, 777
hypotension in, 775
management of
aortic tear with, 774775
chest tube for, 774, 774f
delayed transport with, 775
hemothorax in, 774, 774f
inadequate analgesia with, 776777
incomplete hemothorax decompression
with, 774
incomplete pleural decompression with,
773774
indications for, 773
missed aortic tear with, 774775
phrenic nerve injury with, 775
pneumothorax in, 773774, 774f
retained hemothorax with, 777
steps in, 773
unrecognized abdominal injury with, 775
unrecognized diaphragm injury with,
776, 776f
unrecognized right thoracic injury with,
775
rib fracture in, 776777
Thoracodorsal nerve, dissection-related injury
to, 466467, 466f, 467f
Thoracotomy, in damage control surgery,
800
Thorax
empyema of, chest tube insertion and, 136
137
trauma to. See Thoracic trauma
Thrombectomy, arteriovenous access and,
635, 636f
Thrombocytopenia
pulmonary artery catheterization and, 127
splenectomy and, 573
ablation and, 647
Thrombosis
access site, endovascular intervention and,
653
arterial, bronchial and vascular sleeve
lobectomy and, 690691
arteriovenous access and, 632635
celiac artery, laparoscopic Nissen
fundoplication and, 184
graft, infrainguinal revascularization and,
627
pulmonary artery, pneumonectomy and,
696698
radial artery, cannulation and, 129
superior mesenteric artery, laparoscopic
Nissen fundoplication and, 184
venous, 39, 4142, 42t
central vein catheter and, 116117
Thymectomy, 717721
brachiocephalic vein injury with, 718719
dissection for, 718721, 718f, 719f
hydrothorax with, 720
indications for, 717
median sternotomy for, 717718
mediastinitis with, 717718
myasthenic crisis with, 720721
phrenic nerve injury with, 719, 719f
pneumothorax with, 720
 898 INDEX
Thymectomy (Continued)
recurrent laryngeal nerve injury with, 719
720, 720f
respiratory embarrassment with, 717718
steps in, 717
thymic vein injury with, 718719
transcervical, 717
transsternal, 717
Thymic vein, injury to, 718719
Thymus, vs. parathyroid glands, 410
Thyroid hormone, 404
Thyroid surgery, 397404
airway management for, 398, 398f
cervical dissection for, 398403, 398f,
400f
esophageal injury with, 403
hematoma with, 404
hemostasis for, 403404
hyperthyroidism after, 404
hypoparathyroidism after, 400401, 401t
hypothyroidism after, 404
indications for, 397
nerve injury with, 401403, 401t
recurrent laryngeal nerve injury with, 401
402, 401t
steps in, 397398
superior laryngeal nerve injury with, 402
403
sympathetic chain injury with, 403
thoracic duct injury with, 403
thyroid hormone management after, 404
tracheal injury with, 403
Tibial nerve, infrainguinal revascularization
related injury to, 616
Tibial vein, infrainguinal revascularization
related injury to, 615616
Tidal volume monitoring, in congenital
diaphragmatic hernia repair, 860
To Err Is Human, 1
Total parenteral nutrition, preoperative, 38
39, 38f
Tourniquet, for isolated limb perfusion, 499
Trachea
compression of, thyroid surgery and, 398,
398f
injury to
thyroid surgery and, 403
tracheoesophageal stula repair and, 851
852
Tracheal resection, 741751
airway division for, 746, 746f, 747f
airway edema after, 751
airway loss before, 742
anastomosis for, 747750, 747f, 748f
anastomotic dehiscence with, 746, 748
750, 749f
chin stitch for, 750, 750f
circumferential dissection for, 742745,
743f
cross-table ventilation for, 746747
drain placement for, 743, 743f
esophageal injury with, 745, 745f
extubation for, 751
feeding after, 745
granulation formation with, 747748
high-frequency jet ventilator cannula for,
746747, 747f
indication for, 741
paraplegia after, 750
recurrent laryngeal nerve injury with, 743
745, 744f
restenosis after, 746, 748750
rigid bronchoscopy for, 741742, 742f
steps in, 741
steroid weaning before, 750
suture material for, 747
Tracheal resection (Continued)
tension-releasing maneuvers for, 745746,
746f
Tracheoesophageal stula repair, 849855
end-to-end anastomosis for, 853854, 853f
esophageal injury with, 851852
esophageal leak with, 853
esophageal stenosis with, 853854
stula division for, 850851, 850f
stula ligation for, 850851, 851f
GERD after, 854855
indications for, 849
long gap atresia and, 852853, 852f
long thoracic nerve injury with, 850
posterolateral thoracotomy for, 849850
pouch dissection for, 851853
recurrent stula after, 854
right-sided aortic arch and, 849850
steps in, 849
tracheal injury with, 851852
Transcutaneous oxygen tension, 613
Transfer, for trauma, 766, 775
Transfusion therapy, in damage control
surgery, 804
Trauma
abdominal. See Abdominal injury; Damage
control surgery
blunt
bleeding with, 769, 770f
hypotension in, 769770
shock with, 769770
brain. See Traumatic brain injury
cerebrovascular, 768769, 769b
duodenal. See Duodenal injury
evaluation and acute management of, 757
770
air embolism with, 762
airway in, 757761, 758f760f
airway loss in, 757, 758f
blind clamping with, 762763
breathing in, 761762
central venous access complications with,
765766
circulation in, 762763
delayed transfer with, 766
disability assessment in, 763764
early intervention for, 765766
in elderly patient, 763
exposure/environmental factors in, 764
765
failure to intubate with, 763764
femoral venous cannula with, 765766
gastric decompression for, 766
Glasgow Coma Scale in, 763764, 764t
gunshot wound assessment in, 767
hemorrhage with, 762, 763
hypotension with, 764
hypothermia with, 764765
hypoxia in, 757, 760
insufcient IV access with, 765
mental status changes in, 764
missed injury with, 767
missed shock diagnosis with, 763
missed spinal cord injury in, 764
missed tension pneumothorax with, 761
nasogastric tube misplacement with, 766
neurologic injury with, 761
primary survey in, 757765
secondary survey in, 767
spine manipulation in, 761
tension pneumothorax with, 761762
transfer for, 766
unnecessary chest tube placement with,
761, 762
unstable airway in, 760761
urethral tear with, 766
Trauma (Continued)
vascular injury with, 762763
venous access for, 765766
literature evaluation on, 753755
class II data in, 754
class III data in, 753754
retrospective vs. prospective series in,
754
neck. See Neck injury
pancreatic. See Pancreatic injury
pelvic. See Pelvic injury
splenic. See Splenic injury
thoracic. See Thoracic trauma
Traumatic brain injury, 785789
cerebral perfusion pressure in, 787, 787b,
788f
computed tomography in, 786, 786f
diabetes insipidus with, 789
Glasgow Coma Score in, 785, 786t
guidelines for, 785, 786f, 786t
hypovolemia with, 788
intracranial hypertension with, 787, 787b
intubation for, 785, 786t
mental status changes with, 787
osmotic diuretics in, 788
outcomes of, 785, 786t
subdural hematoma with, 788789, 788f
Trendelenburg position, reverse, cardiac
output with, 101
Tricuspid valve, catheterization-related injury
to, 127
Trisectionectomy, 345356
argon beam coagulation for, 347
bile duct injury with, 349
bile leak after, 352354
biliary drainage before, 356
bleeding with, 350352
blood transfusion for, 350
cholangiography before, 353
cholangiography during, 354
clamp-crushing technique for, 352
clamping techniques for, 351
dissecting sealer device for, 352
endoscopic retrograde
cholangiopancreatography after, 353
brin sealant for, 347348, 354
hemorrhage with, 349352
hepatic artery injury with, 348349
hepatic insufciency after, 354356
hepatic vein injury with, 349350
hepatic volume in, 355356
Hydrojet for, 352
inadequate exposure with, 346347
incision for, 346347
indications for, 345
indocyanine green test in, 355
inferior vena cava injury with, 349350
inow vessel control for, 348349, 349f
liver mobilization for, 347348
methylene blue testing during, 354
monoethylglycinexylidide test in, 355
morbidity with, 345
mortality with, 345, 353
necrosis with, 348349
outow vessel control for, 349350
parenchymal transection for, 350354
pleural effusion after, 347348
portal vein embolization in, 356
portal vein injury with, 348349
Pringle maneuver for, 348, 351
residual function after, 355
selective hepatic venous exclusion for, 352
steps in, 345346
total hepatic venous exclusion for, 351
352
ultrasonic dissector for, 352

Trocar insertion
for adrenalectomy, 426, 426f
for appendectomy, 300301, 300f
for cholecystectomy, 320, 320f
for esophagomyotomy, 189
for incisional hernia repair, 537, 538f
for inguinal hernia repair, 516, 516f
for laparoscopic Nissen fundoplication, 175
for laparoscopic surgery, 97100, 97f, 99f
for right colectomy, 258
for splenectomy, 572573, 573f
Trousseaus sign, 400
Tube. See Gastrostomy feeding tube;
Jejunostomy feeding tube; Nasogastric
tube
Turcot syndrome, 44t
U chylous ascites after, 169
Ulcer
duodenal
Helicobacter pylori infection and, 163
164
perforation of
enlargement of, 160
after Graham patch repair, 164, 164b
nonoperative treatment of, 159, 160b
operative treatment of. See Graham
patch repair
sealed, 159, 160
pyloroplasty for. See Pyloroplasty
vagotomy for. See Vagotomy
gastric, after laparoscopic Nissen
fundoplication, 183184
Ulceration, venous, subfascial endoscopic
perforator surgery for, 647648
Ulnar nerve block, 53t, 55, 56f
Ultrasonography
in breast biopsy. See Breast biopsy, image-
guided, ultrasound
in central vein catheterization, 110111
in infrainguinal revascularization, 624
in laparoscopic hepatectomy, 362, 362f
in parathyroidectomy, 414, 414f, 416
Umbilical hernia. See Hernia, umbilical
Ureter, injury to
aortobifemoral bypass and, 603
appendectomy and, 302303
colectomy and, 259260, 266267, 266f,
267f
damage control surgery for, 802
laparotomy and, 82
rectal resection and, 277278, 278f, 286
287
Urethra, injury to
abdominal perineal resection and, 293294
anoplasty and, 829
trauma and, 766
Urethral diverticulum, 831
Urinary catheter, in trauma, 766
Urinary incontinence, anal stulotomy and,
316317
Urinary retention
anal stulotomy and, 315
hemorrhoidectomy and, 307308
Urinary tract infection, after pediatric
colostomy, 831
Urinoma, laparotomy and, 82
V intercostal bundle injury with, 672673
V-Y advancement ap, in total mastectomy,
481482, 482f
Vacuum-assisted closure, 91, 91f
Vagal trunk, injury to, laparoscopic
esophagomyotomy with Dor
fundoplication and, 194
Vagina, injury to
abdominal perineal resection and, 294
anoplasty and, 829
rectal resection and, 286
Vagotomy, 167172
aortic injury with, 172
dysphagia after, 169
esophageal perforation with, 168169,
168f
inadequate drainage after, 170171
incomplete, 169170
division and resection for, 169170, 170f
liver mobilization for, 168
vagus nerve identication for, 168169
indications for, 167
phrenic vein injury with, 168
pneumothorax with, 172
splenic injury with, 169
steps in, 167
thoracic duct injury with, 169
Vagus nerve
in carotid endarterectomy, 588, 588f
injury to
carotid endarterectomy and, 589
laparoscopic Nissen fundoplication and,
176, 177f
mediastinal mass resection and, 723724
Varicose veins, 643647
stab avulsion of, 647
vein ablation for, 645647, 646f
vein ligation for, 645
vein stripping for, 643645, 644f
Varix (varices)
vs. adrenal tumor, 422f
ileostomy-related, 254
Vas deferens, hernia repairrelated disorders
to, 504505, 867
VATS lobectomy. See Video-assisted thoracic
surgery (VATS) lobectomy
Venography, in arteriovenous hemodialysis
access, 631, 632b, 634, 636
Venous insufciency, supercial, 643. See also
Varicose veins
subfascial endoscopic perforator surgery for,
647648
Ventilation-perfusion mismatch, laparoscopic
surgery and, 102
Veress needle, 97, 98, 98f, 99, 198
retroperitoneal vascular injury with, 99100,
100f
Vicryl mesh, in damage control surgery
closure, 806
INDEX 899
Video-assisted thoracic surgery (VATS)
lobectomy, 671683
chylothorax with, 682
esophageal injury with, 674, 674f
indications for, 671
left lower, 675676, 676f, 679, 681
left upper, 675, 681, 681f
lung mobilization for, 673674, 673f
lymph node dissection for, 682683
phrenic nerve injury with, 673674
port placements for, 672673, 672f
pulmonary vessel isolation and division for,
681682
recurrent laryngeal nerve injury with, 682
683
right lower, 675, 679, 681
right middle, 675, 679, 681f
right upper, 674675, 675f, 676679,
677f678f, 679f, 680f
steps in, 672
vascular injury with, 681682
Visualization, 56, 2021
Vitamin B12 deciency, after enterectomy, 245
Voice, thyroid surgeryrelated changes in, 402
Volvulus, 819825
delayed diagnosis of, 821
development of, 819820, 820f
diagnosis of, 820821, 821f
Ladd procedure for, 821, 822f
delayed, 821
mesentery injury with, 823
recurrent volvulus after, 822823
small intestinal obstruction after, 823
recurrent, 822823
Vomiting
in isolated limb perfusion of melphalan,
499
postoperative, 6364, 64b, 64t
after pyloromyotomy, 873, 874
Von Willebrand disease, 39, 40t
W
Whipple procedure. See
Pancreaticoduodenectomy
Whitehead deformity, hemorrhoidectomy and,
310
Wilms tumor, 861863
vs. neuroblastoma, 864, 864f
removal of, 861863
bleeding with, 863
contralateral tumor with, 861862
contralateral vessel injury with, 862
dissection for, 863
exploration for, 861862
incision for, 861
liver resection with, 863
pulmonary embolism with, 863
renal hilum ligation for, 862863, 862f
steps in, 861
tumor spillage with, 861, 862863
Withdrawal syndrome, alcohol, 2930, 29b,
30f
Wound infection. See Infection, wound