Operative Procedures in Surgical Gastroenterology Volume II

Operative Procedures in
Surgical Gastroenterology
Operative Procedures in
Surgical Gastroenterology
Volume II
Editor
SP Kaushik
MBBS (Lko) FRCS (Edin) PhD (London)
FICS FACG FAMS (Academy of Medical Sciences, India)
Former
Professor and Head, Department of Surgical Gastroenterology
Sanjay Gandhi Postgraduate Institute of Medical Sciences
Lucknow, India
Professor and Head

Department of Surgery
Government Medical College and Hospital,
Chandigarh, India
President
Indian Association of Surgical Gastroenterology
Member, Governing Council
Association of Surgeons of India
Indian Society of Gastroenterology
Advisor
Indian Armed Forces
Rajiv Gandhi Cancer Institute and Research Centre
New Delhi, India
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Operative Procedures in Surgical Gastroenterology Volume II

© 2009, SP Kaushik
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or
transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise,
without the prior written permission of the editor and the publisher.
This book has been published in good faith that the material provided by contributors is original. Every
effort is made to ensure accuracy of material, but the publisher, printer and editor will not be held
responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under
Delhi jurisdiction only.
First Edition: 2009

ISBN 978-81-8448-569-1
Typeset at JPBMP typesetting unit
Printed at
To My
Parents
Family
Students
and
Patients
CONTRIBUTORS
Anil Agrawal
Department of Surgical Gastroenterology
GB Pant Hospital, New Delhi
Wasif Ali
Chief Surgical Gastroenterology Surgeon
Clair Hospital, Hyderabad
Adarsh Chaudhary
Sir Ganga Ram Hospital, New Delhi
Pradeep K Chowbey
Department of Minimal Access Surgery and Bariatric Centre
Puneet Dhar
Professor and Head
Amrita Institute of Medical Sciences, Cochin
Unnikrishnan G
Vinay Kapoor
Lucknow
SP Kaushik
Former Professor and Head
Sanjay Gandhi PGI, Lucknow
House No.132, Sector 6
Panchkula 134 109
spkaushik@hotmail.com
viii Operative Procedures in Surgical Gastroenterology
Ashok Kumar
Lucknow
Pradeep R
Chief of Surgical Gastroenterology
Asian Institute of Gastroenterology, Hyderabad
Richa Lal
Lucknow
Magnus J Mansard
Ramachandran Menon
Azhar Pervaiz
GV Rao
RA Sastry
Nizam’s Institute of Medical Sciences, Hyderabad
Vibha Varma
Nizam’s Institute of Medical Sciences, Hyderabad
Sadiq S Sikora
Institute of Gastroenterology
Manipal Hospital, Bengaluru
Contributors ix
Dinesh Singhal
Amanjeet Singh
Rajneesh Kumar Singh

Lucknow
Vandana Soni
Department of Minimal Access Surgery and Bariatric Centre
Avinash Kumar Tang

Lucknow
TD Yadav
Department of General Surgery
Postgraduate Institute of Medical Education and Research
Chandigarh
PREFACE
The first edition of the book was published in 2001

and listed 29 procedures. A number of advances in
surgical gastroenterology, development of sub-
specialties, expertise and newer operative techniques
have made one feel the need of updating. Hence this
second volume of the book.
The earlier book has proved to be extremely useful
to its readers. This observation is based on positive
feedback from different sources. This previously
published book has now been titled as Volume I and
the present one as Volume II, which contains
additional operative procedures pertaining to the
superspecialty of surgical gastroenterology. I do hope
the second volume of the book would also prove its
worth by helping young surgeons, MCh and non-
MCh residents, DNB students, new faculty members
and the specialty oriented general surgeons in
performing successfully more complex operative
procedures in surgical gastroenterology, particularly
in situations where personal guidance and supervision
of an expert may not necessarily be available.
The present era and the future of any specialty lies
in developing subspecialties. From personal
experience, I would say that it has indeed been a great
effort to change the mindset of involved people and
to convince them for a total commitment for
xii Operative Procedures in Surgical Gastroenterology
developing subspecialties, i.e. liver, biliary, pancreatic,

luminal, revision surgery, etc.
I am indeed happy to see that this policy has paid
dividends in the long run, and that department at
Sanjay Gandhi Postgraduate Institute of Medical
Sciences, Lucknow has now established itself firmly
as one of the best departments of surgical
gastroenterology.
SP Kaushik
CONTENTS
1. Surgery for Gastroesophageal

Reflux Disease ....................................................... 1
Pradeep R, Magnus J Mansard, GV Rao
2. Gastric Pouch Formation .................................. 17

Anil Agrawal
3. Laparoscopic Restrictive Bariatric

Procedures ............................................................. 29
Pradeep K Chowbey, Vandana Soni
4. Pancreas Preserving Duodenectomy .............. 55

TD Yadav
5. Transduodenal Resection of Ampulla .......... 63

TD Yadav
6. Median Pancreatectomy .................................... 71

Adarsh Chaudhary, Amanjeet Singh
Azhar Pervaiz, Dinesh Singhal
7. Distal Pancreatectomy ........................................ 79
Sadiq S Sikora
8. Biliary Surgery in Portal Hypertension ....... 93

Richa Lal, Avinash Kumar Tang, Vinay Kapoor
9. Portacaval Shunt in the Treatment of

Portal Hypertension ......................................... 109
RA Sastry, Vibha Varma
10. Portal Vein Resections and Injuries ........... 141

Rajneesh Kumar Singh, Vinay Kapoor
xiv Operative Procedures in Surgical Gastroenterology
11. Pelvic Exenteration ........................................... 159

Puneet Dhar, Unnikrishnan G
12. Radical Cytoreductive Surgery for

Pseudomyxoma Peritonei ................................ 171
Puneet Dhar, Ramachandran Menon
13. Surgery for Complex Anal Fistula ............... 185

Ashok Kumar
14. Colostomy ........................................................... 207

Wasif Ali
15. Record Keeping, Data Collection and

Audit for Individual Surgeons ..................... 227
SP Kaushik
16. Postoperative Complications of Surgery:

Social Consequences and Ethical
Considerations ................................................... 237
SP Kaushik
Index ...................................................................... 251

FROM THE EDITOR’S DESK
The development of the superspecialty of Surgical

gastroenterology, as an independent branch of surgery has been
the result of untiring and pioneering efforts in creating separate
departments in general surgery, with or without an MCh degree
program at Madras Medical College and Hospital, Chennai
(Prof N Rangabhashyam), at AIIMS, New Delhi (Prof BML
Kapoor and Prof Samiran Nundy), at GB Pant Hospital, New
Delhi (Prof RC Aranya) and at Sanjay Gandhi Postgraduate
Institute of Medical Sciences, Lucknow. MCh in surgical
gastroenterology was started on the basis of only regional
intake of students at Chennai in 1977 and for the first time in
the country, on the basis of All India National intake of students
at SGPGI, Lucknow in 1993.
A number of other institutions have also now come up, both
in private as well as in public sector, with the superspecialty
departments. The National Board of Examinations has also
started DNBE in surgical gastroenterology after identifying and
recognizing various training centres.
The superspecialty has thus come a long way today. It has
been possible to raise a committed cadre of young specialists,
besides establishing a number of large volume centres, giving
first rate clinical care with minimum procedure related morbidity
and mortality comparable to any place in the world. Some
meaningful research has also been done using excellent clinical
material available. On the face of it, a reasonable data has been
collected for evidence-based medical care.
The development of the specialty till date has therefore,
proved the skeptics wrong, who feared that the separation of
yet another specialty of gastroenterology surgery, from the
general surgery would result into general surgeons being
labeled as ‘residual surgeons’. Little they realized that it was
not what general surgery stood to lose, if at all any thing, but
xvi Operative Procedures in Surgical Gastroenterology
a new medical science! Like neurosurgery, cardiac surgery,

urology and others, it would not have been possible for the
specialty of surgical gastroenterology to have made such strides,
had it remained as a mere part of general surgery. For the sake
of providing the best possible tertiary care at a reasonable cost
to our own population, the challenge of specialty development
had to be met successfully, thus upgrading the medicare
spectrum in its totality under the health care program and other
policies. It is also mandatory for the facilities and the level of
care to improve to international standards if the advantage of
medical tourism has to be sustained.
The medical science of gastroenterology today, consists of
two major clinical divisions, i.e. medical gastroenterology and
surgical gastroenterology. The dominant role played by medical
gastroenterologists so far has to be appreciated but at the same
time one looks with satisfaction, the matching contributions
made by surgical gastroenterologists in a relatively short time,
in upgrading the surgical counterpart to the similar heights. This
has no doubt resulted into coordinated and committed surgical
support, evolved joint management strategies, improved
management and outcome of complicated and critically ill-
patients and has made use of the latest advancements and
developments in modern technology to its best.
Now is the right time for surgical gastroenterologists to shift
their emphasis on to the development of subspecialties. The
subspecialties which need to come up as semi independent units
include biliary surgery, surgery of the liver along with
transplantation, pancreatic surgery, luminal surgery including
anorectal and sphincter saving procedures, small bowel
transplant, GI oncology, minimal access surgery, robotics and
virtual reality, revision surgery, evidence-based surgery,
telemedicine, networking, etc. Every centre should decide upon
their priorities and commit to create a large volume experience.
The pool of practitioners of surgical gastroenterology in the
present era, is constituted by MCh qualified specialists, DNBE
qualified superspecialists, non MCh senior residents in dedicated
departments who are trained at par with MCh postgraduates,
along with committed general surgeons. The need of the hour
From the Editor’s Desk xvii
is to increase the number of such committed surgeons by

establishing more and more specialized centers with a clearly
defined mandate, an honest and sincere work ethos, and a
structured training program. (It is obligatory for these centers
to generate patient related data with absolute honesty, audit
one’s records and archive them for the future).
The training program in the superspecialty of surgical
gastroenterology also needs to emphasize and take care of
overall consolidation and enhancement of resident’s talent and
bringing out the best in them. The curriculum has to be relevant,
well thought of and worked out with the help of a Board of
Studies consisting of peers in the field. The teaching and training
has to be practical, patient-oriented and ought to inculcate ability
to take immediate decisions in face of unexpected developments
during surgery and/or in the pre and postoperative period.
Due emphasis needs to be given to faculty commitment and
participation in teaching sessions. Hands on operating
experience under supervision, in order to give the resident
adequate level of confidence is a must in order to develop a
well-qualified, competent and trained man power for the care
of patients with surgical GI problems. The infrastructure
provided has to match the expectations from highly trained
superspecialists.
The number of total seats available for MCh registration of
students in surgical gastroenterology is grossly inadequate as
compared to the requirement and the demand. More and more
centers need to come up with postdoctoral degree programs
and the restriction for regional intake only for the students
entering these superspecialty based courses must end. The
National Board of Examinations has recently started DNB
examination in surgical gastroenterology. Till date more than
twenty centers have been recognized for such training. DNB
in surgical gastroenterology, by and large is a noninstitutional
based program, mostly run by private hospitals. The program
often lacks in structured training and graded residency
schedules. In addition, the practical operating experience is
grossly deficient because of inability to operate independently
by their own (hands on experience) the patients with major
xviii Operative Procedures in Surgical Gastroenterology
surgical problems. During their practical clinical examination,

majority of these residents are also not able to appreciate the
importance of good preoperative and postoperative care, i.e.
need and method of controlling blood sugar before and after
surgery, management of fluid and electrolytes, central line,
intravenous line problems, Ryle’s tube and drain problems and
response to any sudden unexpected development or a
complication. The ability to take independent on the spot
decision is far from within acceptable limits. Similarly, during
surgical intervention, any development other than routine, is
hardly ever appreciated and handled with confidence, expected
of a superspecialist. The management of intraoperative accidents
is poorly understood as is the need to deviate or change the
planned procedure in such situations. In contrast, residents from
academic departments do get a much better operative
experience and spend good time in the wards looking after
patients in pre and postoperative period.
Another aspect of surgical practice which needs urgent
attention is the ethical conduct and practice by surgeons and
specialists. The malpractice arena consists of patients who had
to suffer from snatching, undercutting (there is no uniform fee
structure), kick backs and reward systems, advertising, making
false indications for surgery, cooking up of data, making false
claims and running down colleagues, etc. By and large no ethical
monitoring of personal conduct of an individual is done. A large
number of medical institutions do not even have a properly
constituted ethical committee and if they do exist, these
committees confine their working only to research proposals.
Further, the authority to implement an adverse decision on any
violation of ethical limits by a single or a group of individuals
does not really lie with the committee.
A positive change is therefore required in the public mindset
as the demand for more and more specialized and latest
treatment increases with advancements in Science and
Technology. A matching change in the vision and commitment
of surgical fraternity is also required in order to give their best
for alleviation of human suffering. At the same time, the change
From the Editor’s Desk xix
in attitude and approach of medical administrators and political
leadership to provide the best medicare facilities to the
population is also required. The action plan ought to lay greater
emphasis on infrastructure development, quality control
including that of medical man power and establishment of at
least one tertiary level apex medical institution.
The challenge for the surgical gastroenterologists of today
and tomorrow is indeed awesome. They must perform their
best and win over the scientific community as well as the public,
resolve to make a positive contribution to the advancement of
surgical gastroenterology, improve rating of their publications,
i.e. impact factor and citation index, and do meaningful research
(honest data base). The natural public reaction to surgical
interventions is that of resistance and hesitation. They must be
made to understand that surgery is also a form of treatment
and has indeed been a successful option since Sushruta’s times
and may well be the only option in many situations. The inborn
resistance against surgery must go. However, the surgical
practitioners need to weigh the risks of intervention more
seriously and have preoperative detailed discussions with the
patient and his or her relations.
I do hope that both these volumes of the book would be
of help to young faculty as well as to residents, in particular,
those taking DNB training and examinations and strengthen
their confidence and fill the void.
I take this opportunity to express my sincere thanks to all
my colleagues who have contributed chapters to these volumes.
I would also like to thank my teachers and senior colleagues
who were able to guide me in taking up the challenge of
developing surgical gastroenterology. But for their efforts in
spite of all the hardships they faced themselves, it would not
have been possible to progress and reach the pinnacle in one’s
life. My stay at Sanjay Gandhi PGI, Lucknow had been a
memorable one, almost a dream come true for me. I have a
great feeling of satisfaction and am very proud of my faculty
and alumni. They have indeed helped me sustain my faith in
my oft repeated statement, “If you have trained your residents
xx Operative Procedures in Surgical Gastroenterology
well, they should be good enough to operate upon you as and

when such a need arises”.
The superspecialty of surgical gastroenterology has come
a long way in the last three decades but there is still a long way
to go. In the end, I would like to quote Robert Frost
(1874-1963) who wrote,
“The woods are lovely, dark and deep

But I have promises to keep
And miles to go before I sleep
And miles to go before I sleep”
CHAPTER 1
Surgery for
Gastroesophageal
Reflux Disease
Pradeep R
Magnus J Mansard
GV Rao
2 Operative Procedures in Surgical Gastroenterology
INTRODUCTION
GERD is defined as the failure of the antireflux
barrier, allowing abnormal reflux of gastric contents
into the esophagus. It is a mechanical disorder which
is caused by a defective lower esophageal sphincter,
a gastric emptying disorder or failed esophageal
peristalsis. Surgical treatment of GERD is well-
established and provides well-recognized benefits.
Nissen fundoplication is the most common surgical
approach in the correction of gastroesophageal reflux.
There continues to be considerable debate on some
of the technical aspects of these procedures and on
the long-term difference in outcome between partial
and complete fundoplication.
INDICATIONS
• Failure of medical management
• Patient opts for surgery despite successful medical
management (due to life style considerations
including age, time or expense of medications,
undesirable side effects, poor compliance, etc.)
• Patient develops of GERD complications (e.g.,
stricture; grade 3 or 4 esophagitis)
• Patient has “atypical” symptoms (asthma,
hoarseness, cough, chest pain, aspiration) and
reflux documented on 24 hour pH monitoring- the
“aspirators.”
Surgery for Gastroesophageal Reflux Disease 3
• Patient develops Barrett’s changes, especially when

he is symptomatic, has a long segment of Barrett’s,
and in particular when he is younger than 50 years
of age. In patients with Barrett’s changes and severe
dysplasia, the risk of underlying malignancy may
suggest consideration of esophagectomy, rather
than antireflux surgery.
PREOPERATIVE WORKUP
All patients who are candidates for a laparoscopic
fundoplication should undergo a preoperative
evaluation that includes the following:
• Symptomatic evaluation: The presence of both
typical symptoms (heartburn, regurgitation, and
dysphagia) and atypical symptoms of GERD
(cough, wheezing, chest pain and hoarseness)
should be investigated.
• An upper GI series: An upper GI series is useful
for diagnosing and characterizing an existing hiatal
hernia. Esophagograms are also useful for
determining the location, shape, and size of a
stricture and detecting a short esophagus.
• Endoscopy: Endoscopy is most valuable for
excluding gastric and duodenal pathologic
conditions and detecting the presence of Barrett’s
esophagus.
• Esophageal manometry: Esophageal manometry

provides useful information about the motor
function of the esophagus by determining the
length and resting pressure of the lower eso-
phageal sphincter (LES) and assessing the quality
(i.e., the amplitude and propagation) of esophageal
peristalsis.
• Ambulatory pH monitoring: Ambulatory pH
monitoring is the most reliable test for the
diagnosis of GERD, with a sensitivity and
specificity of about 92%.
SURGICAL TECHNIQUES
Position
The patient is placed in the supine position. A sternal
retractor is used to lift the sternum and the costal
arch forward. Abdominal retractor is used to separate
the wound edges laterally. Exposure is improved by
bending the patient at the waist by 20°- 30° and by
bending the headpiece backward by a similar amount.
This shifts the abdominal wound in a cranial direction
and flattens the diaphragm to improve access to the
hiatal region.
Incision
Upper midline abdominal incision of about 8 inches
extending from between the xiphisternum and the left
costal margin to just above or below the umbilicus.
Steps of Operation
• The left lobe of the liver is raised forward to
expose the junction between the stomach and the
esophagus.
• The stomach is retracted and the gastrohepatic
ligament is divided above and below the hepatic
branch of the vagus (Fig. 1.1).
• Dissection begins above the caudate lobe of the
liver, where this ligament usually is very thin, and
continues toward the diaphragm until the right
crus is identified.
• An accessory left hepatic artery originating from
the left gastric artery is encountered in
approximately 5% in the gastrohepatic ligament.
Preservation of the hepatic branch of vagus makes
injury to this vessel unlikely. If this vessel creates
problems of exposure, it may be divided.
• The peritoneum and the phreno-esophageal
membrane above the esophagus are divided
thereby exposing both the hiatal pillars as far
posteriorly as possible.
• Anterior vagus branches running along the anterior
wall of the esophagus are not dissected from the
esophageal wall and are included in the wrap.
• Posterior vagus is usually found separately behind
the esophagus. It is displaced further posteriorly
and is not included in the wrap.
• Via blunt and sharp dissection, a window is created
under the esophagus between the gastric fundus,
the esophagus, and the diaphragmatic crura.
Fig. 1.1: Division of gastrohepatic ligament sparing hepatic

branch of vagus nerve
• The window is enlarged and a Penrose drain is

passed around the esophagus. This drain is then
used for traction and the posterior aspect of the
distal esophagus is fully mobilized.
• The diaphragmatic crura are closed with
interrupted 2-0 silk. Exposure is provided by
retracting the esophagus upward and toward the
patient’s left with the Penrose drain (Fig. 1.2).
• The first stitch should be placed just above the
junction of the two crura. Additional stitches are
Fig. 1.2: Approximation of diaphragmatic crura by

interrupted silk sutures
placed 1 cm apart, and a space of about 1 cm is

left between the uppermost stitch and the
esophagus.
• A 52 French bougie is inserted by the
anesthesiologist and passed through the
esophagogastric junction. The crura must be snug
around the esophagus but not too tight. The short
gastric vessels are divided to achieve what is called
a floppy fundoplication.
• Dissection begins at the level of the middle portion
of the gastric body and continues upward until the
most proximal short gastric vessel is divided and
the Penrose drain is reached.
• The top of the stomach, after being freed from its
attachments, is taken through the space created
behind the esophagus
• The left and right sides of the fundus are wrapped
above the fat pad (which lies above the esopha-
gogastric junction) and held together in place.
• Use of the “shoeshine” maneuver prior to
completing the fundoplication ensures that the
stomach is not twisted and that the proper portion
of the stomach is employed in the repair; the
surgeon grasps both ends of the fundus and pulls
it back and forth behind the esophagus to ensure
adequate mobility and no tension.
• Usually, three 2-0 silk sutures are used to secure
the two ends of the wrap to each other (Fig.
1.3).
Fig. 1.3: The stomach wraps arround the esophagus
• The sutures are passed deeply though the serosa

and the muscle of the stomach on either side and
also more superficially through the muscle of the
esophagus.
• To test the tightness of the wrap a 52 Fr bougie
is passed. It should be possible for the surgeon to
pass a finger between the bougie and the wrap.
Wound Closure
Hemostasis and the position of the nasogastric tube
are checked and the abdomen is closed in layers.
POSTOPERATIVE CARE
Intravenous fluid and free nasogastric drainage are
continued until peristaltic activity returns.
The consistency of the food is progressively increased.
The patient warned first about the need to chew all

foods carefully in order to avoid dysphagia, and
second about the need to take frequent meals in the
early postoperative period in the event of early
satiety.
COMPLICATIONS
Intraoperative and Early Complications
Intraoperative complications include esophageal and
gastric perforations, splenic injury, bleeding, and
missed visceral injury.
Esophageal and gastric perforations occur in
approximately 1.5% of cases; if detected, they are
repaired primarily, and drains are placed to minimize
the risk of peritonitis or mediastinitis.
Splenic injury can take the form of infarction or
bleeding. Superior pole infarction can occur with
ligation of the short gastric arteries and does not
require intervention. Splenic bleeding may require
conversion to a laparotomy and urgent splenectomy.
The rate of splenectomy should be less than 1% in
experienced hands.
Cautery injury can result in delayed intestinal
perforation and peritonitis. Meticulous dissection and
gentle retraction can help prevent injury.
Late Complications
Although Nissen fundoplication has greater than 90%
success in eliminating reflux symptoms, over time a
proportion of patients develop new or recurrent

foregut symptoms. Some dysphagia, gas bloating,
and mild residual esophagitis are common in the early
postoperative period, but these symptoms generally
resolve within 3 months; severe or persistent
symptoms may indicate failure and the need for
further investigation.
Of patients undergoing Nissen fundoplication, 2%
to 6% eventually require reoperation. Reported
mechanical causes of failure vary significantly among
studies, but transthoracic herniation occurs in 10% to
60% of failures and “slipped” fundoplications are
responsible in approximately 15% to 30% of patients.
A “slipped” or misplaced fundoplication occurs when the
proximal stomach (instead of the distal esophagus) is
wrapped with the fundoplication. Tight fundoplication,
missed motility disorders, and paraesophageal hernias
are other modes of Nissen fundoplication failure.
LONG-TERM RESULTS
Nissen fundoplication is safe, effective, and durable.
Mortality rates associated with Nissen fundoplication
are very low, ranging from 0.008% to 0.8% in large
series. The most likely to benefit from Nissen
fundoplication are those who have abnormal 24-hour
pH testing scores, typical symptoms, and a good
response to medical therapy. Most large studies for
Nissen fundoplication report high patient satisfaction
rates at least 5 years out.
Minimally Invasive Antireflux Surgery

The popularization of laparoscopic fundoplication has
been fueled by both patient demand and growing
familiarity among surgeons with advanced
laparoscopic techniques. In general, laparoscopic
fundoplication is associated with a shorter hospital
stay, decreased postoperative pain, earlier return to
solid food, and better cosmesis than the open
approach. In addition, a laparoscopic approach may
provide better visualization of the hiatus and allow
extended dissection into the mediastinum.
Randomized clinical trials comparing open and
laparoscopic Nissen fundoplication have found no
difference in long-term symptom relief, esophageal
acid exposure, esophageal sphincter pressure,
postoperative dysphagia, and overall satisfaction.
Although laparoscopic Nissen fundoplication has
largely overtaken its open counterpart, it is an
operation that requires advanced laparoscopic skills
and has a significant learning curve.
Hill Posterior Gastropexy

The Hill repair is not a fundoplication per se, but a
recalibration of the antireflux barrier. The Hill repair
aims to secure the esophagogastric junction into the
abdominal cavity, recalibrate the LES, and recreate
the acute angle of His. This is accomplished by
esophageal mobilization, return of the esophagogastric
junction to the abdominal cavity without tension,

crural closure, and suture fixation of the right and left
phrenoesophageal bundles to the preaortic fascia.
The tightness of the sutures is calibrated using
intraoperative manometry
Collis Gastroplasty for Short Esophagus

In about 10% of patients undergoing antireflux
surgery, there will not be adequate intra-abdominal
esophageal length. Because the most common cause
of failure after antireflux surgery is related to
transdiaphragmatic herniation, at least 2.5 cm of
tension-free intra-abdominal esophagus must be
present in order to perform a proper Nissen
fundoplication. In most patients, maximal esophageal
mobilization reaching up to the aortic arch will enable
adequate length to be achieved. However, despite
these efforts, some patients require an esophageal
lengthening procedure such as a Collis gastroplasty.
This procedure creates a tubularized portion of
stomach that acts as a continuation of the esophagus
(Fig. 1.4). The fundoplication is subsequently
performed around the neoesophagus.
Partial Fundoplications
The Toupet fundoplication is a 270-degree posterior
fundoplication that was advocated in patients with
reflux associated with esophageal dysmotility. After
the crura are closed, the fundus is passed posterior
Fig. 1.4: Collis gastroplasty
to the esophagus similar to the approach used for the

Nissen fundoplication. The limbs of the fundoplica-
tion are then sutured together to the anterior
esophagus, taking care to avoid the anterior vagal
trunk. In long-term follow-up, the Toupet repair is
associated with a high symptomatic failure rate.
Mounting evidence in the surgical literature weighs
heavily against the continued use of partial
fundoplication as a primary therapy for medically
refractory GERD even in the presence of dysmotility.
Transthoracic Antireflux Surgery

The thoracic approach has a number of advantages:
• Mobilization of the esophagus permits reduction
and repair without tension;
• When panmural oesophagitis has shortened the

esophagus other corrective measures are possible,
e.g., Collis / Belsy (Pearson procedure), resection
and interposition, or Thal patch;
• Better access to the cardia is afforded, especially
in obese patients and in individuals who have
undergone previous operations at the gastro-
esophageal junction.
BIBLIOGRAPHY
1. Chrysos E, Tsiaoussis J, Zoras OJ, Athanasakis E, Mantides
A, Katsamouris A, Xynos E. Laparoscopic surgery for
gastroesophageal reflux disease patients with impaired
esophageal peristalsis: Total or partial fundoplication? J Am
Coll Surg 2003; 197: 8-15.
2. Draaisma WA, Rijnhart-de Jong HG, Broeders IA, Smout AJ,
Furnee EJ, Gooszen HG. Five-year subjective and objective
results of laparoscopic and conventional Nissen fundoplication:
A randomized trial. Ann Surg 2006; 244: 34-41
3. Nissen R, Rossetti M. Fundoplication and gastropexy in the
surgical treatment of cardia insufficiency and hiatal hernia.
Indications, technique and results. Ann Chir 1997; 51: 547-55.
CHAPTER 2
Gastric Pouch
Formation
Anil Agrawal
INTRODUCTION
Total gastrectomy, though a safe and accepted
procedure, causes permanent loss of secretory,
mechanical and storage functions of the stomach. This
results in various postgastrectomy nutritional
problems which adversely impact the quality of life
of the patient. Different reconstructive procedures
have been developed to prevent or minimize these
disorders. More than 70 types of reconstructions have
been tried suggesting that an optimal procedure of
reconstruction following total gastrectomy is yet to
be established.
An effective reconstruction should aim to create
a larger reservoir for food, to provide a barrier
against intestine-esophageal reflux, and to lengthen
the food transit time. In this regard pouch procedures
were developed to fashion a neo-stomach to act as
a reservoir for food. One such procedure is a Hunt-
Lawrence pouch that has been developed to augment
the neogastrium’s reservoir capacity and to slow
down the rapid emptying of food in the small gut.
It has been shown that food transit through the
pouch follows a linear decreasing function and is
significantly slower compared to the exponential
passage of a simple Roux-en-Y esophagojejunostomy,
although both patterns remain still significantly
accelerated compared to the physiological ranges of
gastric emptying.
Gastric Pouch Formation 19
Several modifications of the Hunt-Lawrence pouch

exists today; notable among these are Lygidakis’s
modification, aboral pouch (15-cm long side to side
antiperistaltic pouch at the Y anastomosis of Roux-en-
Y), or a double pouch (one at the site of
esophagojejunostomy and another at the site of
Y anastomosis of Roux-en-Y). However, this chapter
will be dealing with the classical Hunt-Lawrence
pouch.
INDICATIONS
• As an adjunct procedure to total gastrectomy
• In benign conditions
• In curable malignancy of stomach
• Severe postgastrectomy symptoms
CONTRAINDICATIONS
Pouch formation after total gastrectomy is
contraindicated in patients undergoing palliative
gastrectomy for carcinoma stomach.
SURGICAL TECHNIQUES
Position of Patient
Supine
Incision
Upper midline incision
Steps of Operation
The steps described below are those after total
gastrectomy and using staplers for anastomosis (the
same can be performed by hand-sewn technique):
• Fashioning of Roux loop of jejunum: A linear non
cutting stapler is fired on the jejunum about
10 to 15 cm from duodeno-jejunal flexure, at an
appropriate vascular arcade location after dividing
the mesentery adequately. The jejunum is divided
just distal to the fired stapler, leaving the distal
end open.
• The distal loop of jejunum is then taken up in a
retro-colic manner by creating a window in the
transverse mesocolon.
• Pouch formation: This jejunal loop is folded so as
to have a J limb about 12 cm long and held
together with stay sutures (Fig. 2.1).
• A small enterotomy is made on antimesenteric
part of the long limb, next to the open end of
short limb (Fig. 2.1).
• A linear 75 mm cutting stapler is introduced as
shown in diagram and fired, taking care to
keep the mesentery away by keeping it
stretched out and away from the stapler (Fig.
2.2).
• Another such stapler is fired ahead so that the
septum between the two limbs is totally
divided to make a pouch roughly 12 cm long.
Fig. 2.1: Folding of jejunum on itself,

application of sutures and enterotomy
• Esophagojejunostomy:
– Anvil of a 25 mm circular stapler is introduced
into the cut end of the esophagus.
– A purse string suture is taken at the edge with
2-0 prolene over the anvil (Fig. 2.3).
– Then the shaft of the circular stapler is
introduced through the open end of the
jejunum and the pin is brought out through
apex of the pouch.
Fig. 2.2: Linear cutting stapler in place
Fig. 2.3: Application of a purse string suture

around anvil of endostapler
– This is engaged with anvil in the esophagus and

the stapler is fired forming the anastomosis
(Fig. 2.4).
– The shaft is withdrawn after loosening the anvil
and the doughnuts of esophagus and jejunum
are checked for its completeness.
– The nasoenteric tube is gently guided across the
anastomosis.
• The open end of the jejunum is sutured with the
enterotomy of jejunum in single layer with 3-0 silk
interrupted sutures to complete the pouch
formation. This can also be achieved with a linear
stapling device (Fig. 2.5).
Fig. 2.4: Engaged endostapler in position

Fig. 2.5: Completion of pouch
• Jejuno-jejunostomy is performed in a side-side

manner between the proximal loop and the distal
loop at 70 cm from esophagojejunal anastomosis
with interrupted 3-0 silk sutures in single layer
(Fig. 2.6).
• The mesenteric window is closed and mesocolon
window is approximated around the jejunal loop.
• A feeding jejunostomy is performed by Witzel’s
technique distal to the jejuno-jejunostomy.
Drain
A 28-32F tube drain is placed next to the esophago-
jejunostomy site.
Fig. 2.6: Jejunojejunostomy
Closure
Abdomen is closed en masse with no. 1 loop prolene
and skin approximated with staples.
POSTOPERATIVE CARE
Postoperative management is the same as for any
other patient undergoing total gastrectomy, which
includes—
• NPO and continuous nasogastric aspiration for 5
days
• Vital monitoring.
• Intravenous fluids.
• Epidural or parenteral analgesics are given for

adequate pain relief.
• Perioperative antibiotics are continued in the
postoperative period.
• Chest physiotherapy and graded ambulation are
started from first postoperative day.
• DVT prophylaxis is given as indicated.
• Jejunostomy feeds are started on postoperative
day 3.
• Oral gastrograffin study is done on 5th
postoperative day and patient is started on oral
fluids if the contrast study does not reveal any
leak. Oral intake is gradually increased to solids.
• Drain output is monitored for amount and nature–
blood or enteric contents. Drain is removed in the
absence of blood or enteric contents and when
output is less than 50 ml in 24 hours.
RESULTS
• Results of gastric pouch procedures are varied in
existing world literature with no consensus
whether it should always be offered as an adjunct
to total gastrectomy.
• When the Roux-en-Y pouch procedures are
compared with simple Roux-en-Y esophagojeju-
nostomy, most studies have found that patients
with pouch reconstruction fare better in long term.
But some studies have reported benefits in early
postoperative months also (better eating capacity,
weight gain and quality of life). So, they have

recommended pouch formation even after
palliative gastrectomy.
• But formation of a pouch adds more suture lines,
time and complexities to an already major
operation and chances of leakage are somewhat
increased.
• It has also been reported that some altered
motility occurs after a Hunt-Lawrence pouch
reconstruction even in asymptomatic patients,
which may assume pathological proportions in
symptomatic patients.
• In conclusion, gastric pouch procedure should be
done in patients of total gastrectomy with
likelihood of long term survival, as in benign
conditions or favourable tumors; or for severe
post-gastrectomy syndromes in which non-existent
or insufficient gastric reservoir function is the
possible cause.
BIBLIOGRAPHY
1. Chua CL. Total gastrectomy for gastric cancer: The rationale

for J-pouch reservoir. Jour Roy Coll Surg Edin 1998; 43: 169-
73.
2. Espat NJ, Karpeh M. Reconstruction following total
gastrectomy: A review and summary of the randomized
prospective clinical trials. Surg Oncol 1998; 7: 65-9.
3. Heimbucher J, Fuchs KH, Freys SM, Clark GW, Incarbone R,
DeMeester TR, et al. Motility in the Hunt-Lawrence pouch after
total gastrectomy. Am Jour Surg 1994; 168: 622-5.
4. Hoksch B, Ablassmaier B, Zieren J, Muller JM. Quality of life

after gastrectomy: Longmire’s reconstruction alone compared
with additional pouch reconstruction. World Jour Surg 2002;
26: 335-41.
5. Liedman B, Bosaeus I, Hugosson I, Lundell L. Long-term
beneficial effects of a gastric reservoir on weight control after
total gastrectomy: A study of potential mechanisms. Br Jour.
Surg 1998; 85: 542-7.
6. Liedman B, Hugosson I, Lundell L. Treatment of devastating
postgastrectomy symptoms: The potential role of jejunal pouch
reconstruction. Dig Surg 2001; 18: 218-21.
7. Miyoshi K, Fuchimoto S, Ohsaki T, Sakata T, Ohtsuka S,
Takakura N. Long-term effects of jejunal pouch added to
Roux-en-Y reconstruction after total gastrectomy. Gastric
Cancer 2001; 4: 156-61.
8. Sharma D. Choice of digestive tract reconstructive procedure
following total gastrectomy: A critical reappraisal. Ind Jour.
Surg 2004; 66: 270-6.
9. T Lehnert, K Buhl. Techniques of reconstruction after total
gastrectomy for cancer. Brit Jour Surg 2004; 91: 528-39.
CHAPTER 3
Laparoscopic
Restrictive Bariatric
Procedures
Pradeep K Chowbey
Vandana Soni
INTRODUCTION
Severe obesity is associated with a significant increase
in morbidity and a decrease in life expectancy. It has
been well-established that obesity is associated with
co-morbidities such as heart disease, hypertension,
diabetes mellitus, osteoarthritis, sleep apnea, even
some type of cancers, etc. Medical treatment for
obesity has shown limited results and is associated
with a high failure rate. The approach that has had
the greatest and longest-lasting success in achieving
weight loss is bariatric surgery with significant
amelioration of the associated comorbidities. Bariatric
surgery or surgery for morbid obesity has evolved
gradually over the last 50 years. Its recent popularity
is due to introduction of minimal access approach to
this surgical speciality resulting in significant decrease
in the morbidity and mortality. Bariatric surgery as
a surgical subspeciality started with radical
procedures such as the jejuno-ileal bypass, which
rapidly fell into disrepute due to its high morbidity
and complications. Subsequently two schools of
thought emerged, one, which is more conservative
and relies on restriction and the second, which is
radical and relies mainly on malabsorption. Certain
combination procedures also evolved of which the
gastric bypass enjoys significant popularity.
The popular restrictive procedures are laparoscopic
adjustable gastric banding and laparoscopic sleeve
gastrectomy. Restrictive procedures are associated
Laparoscopic Restrictive Bariatric Procedures 31
with a slower weight loss, however long term results

of weight loss of most bariatric procedures with the
exception of pure malabsorptive procedures are at
par. In addition restrictive procedures are the ones
associated with the lowest incidence of complications,
morbidity and mortality.
Obesity is a lifelong disease and associated with
significant comorbid conditions. The patient suffering
from morbid obesity is therefore best managed by a
multidisciplinary approach. The bariatric multidiscip-
linary team should comprise the surgical team,
nutritionist, psychologist, general physician,
physiotherapist and clinical counselor.
INDICATIONS
The indication for a bariatric procedure is morbid
obesity. According to 1991, National Institute of
Health (NIH) consensus conference guidelines the
patient selection criteria is based on –
Body Mass Index (BMI)

a. BMI >= 40 kg/m2
b. BMI of 35.0 – 39.9 kg/m2 in the presence of severe
comorbidities like Type 2 diabetes, obesity related
cardiomyopathy, sleep apnea, Pickwickian
syndrome, physical problems compromising
lifestyle like joint disease, body size problems
severely interfering with employment, family
function and ambulation.
Age
a. Above 18 years
b. Less than 65 years
Successful Bariatric surgery, however has been
performed on older patients in their 70s and adoles-
cents following a careful evaluation.
CONTRAINDICATIONS
Contraindications include patients suffering from
severe depression, personality disorders, treated or
untreated mental illnesses associated with psychosis,
active substance abuse and bulimia nervosa. These
patients have an adverse outcome following
surgery.
It is important to assess the risk-benefit ratio along
recommended guidelines with proper patient
evaluation for obtaining maximum benefit from these
procedures.
PREOPERATIVE WORK UP
A comprehensive program for preoperative surgical
care should have a multidisciplinary approach with a
well-informed empathetic surgical team to take care
of the patient. Preoperative evaluation of the bariatric
patient is exhaustive and involves educating the
patient about the surgical procedure and the
subsequent lifestyle changes which ensue and which
the patient must voluntarily adopt. This is performed

in the first counseling session of the patient.
• Subsequently the patient undergoes a complete
blood profile that includes a hemogram, liver and
renal function tests, total lipid profile, blood sugar
levels, thyroid functions, HBsAg and Anti HCV
levels.
• EKG, stress echo and pulmonary function tests
assess cardiopulmonary status.
• Special investigations where indicated include an
arterial blood gas, polysomnography, 24 hour
urinary cortisol levels and plasma insulin C
peptide.
• Patients with history suggestive of gastro-esopha-
geal reflux must undergo UGI endoscopy.
• The patient is put on a preoperative low calorie
diet to induce weight loss, assess patient commit-
ment and ease technical difficulty of surgical
procedure, as this diet regimen is known to shrink
the liver size.
• Patient office record must include a preoperative
photograph, blood profile, patient demographic
data and follow up records.
• Preoperative instructions include liquid diet on day
prior to surgery, laxative at bedtime to clear the
bowel, patient consent, 6 hours of complete fasting,
low molecular weight heparin 2 hours prior to
surgery.
OPERATION THEATRE LAYOUT

AND PORT PLACEMENT
The patient is placed in a modified Lloyd Davies
position with the knees slightly flexed and hip
externally rotated. The surgery is performed in a
steep reverse Trendelenburg’s position (Fig. 3.1).
Sequential compression devices are strapped to both
lower limbs to prevent venous stasis.
The operation theatre layout (Fig. 3.2) and port
placement (Fig. 3.3) are as shown in the figures.
SURGICAL PRINCIPLE
Laparoscopic adjustable gastric banding is a form of
reversible gastroplasty. The adjustable gastric band
Fig. 3.1: Patient in steep reverse Trendelenburg’s position

Fig. 3.2: OT layout
is a silicone device placed around the stomach just

below the esophago-gastric junction. The device is
lined by an inflatable reservoir that can be inflated
or deflated postoperatively through a subcutaneous
port placed deep in the abdominal wall for per-
cutaneous access. Saline is injected into or withdrawn
from the reservoir to adjust gastric luminal diameter,
as measured by radiological contrast evaluations.
Thus the band is inflated if the patient is not losing
weight and in the event of vomiting or intolerance
to oral intake the band is deflated. The type of
Fig. 3.3: Port placement
adjustable band commonly placed is a high volume,

low-pressure band and has a maximum balloon
volume capacity of 11 ml.
STEPS OF OPERATION
The Pars Flaccida Technique
• The telescope is inserted through the midline supra
umbilical port. The liver is retracted with a liver
retractor inserted through the right lateral port
(Fig. 3.4). A 20 ml balloon catheter is placed per-
orally into the proximal stomach to calibrate the
size of the gastric pouch.
Fig. 3.4: Liver retractor in position
• The dissection begins at the angle of His. The

peritoneal reflection is divided to mobilize the
angle and develop a plane posterior to the gastro-
esophageal junction medially and gastric fundus
laterally (Fig. 3.5).
• Medially dissection begins at the base of the right
crus. A retrogastric tunnel is created at the
posterior confluence of the diaphragmatic crura in
a plane of dissection that is easily developed with
minimal blunt dissection and electrocauterization.
This tunnel should lie above the free space of the
lesser sac posterior to the stomach (Fig. 3.6).
• Once the tunnel between the lesser curvature and
the angle of His has been cleared a specially
Fig. 3.5: Division of gastroesophageal
Fig. 3.6: Creation of retrogastric tunnel

designed instrument (Goldfinger, Ethicon endo-

surgery) is inserted behind the stomach to emerge
at the angle of His (Fig. 3.7).
• This marks the end of dissection prior to band
placement.
• The band is prepared by aspirating all air and fluid
from the balloon and knotting the tube to maintain
the vacuum. This band is now introduced into the
abdominal cavity through a 15 mm port in the left
mid clavicular region
Fig. 3.7: Goldfinger in situ
• A pre-tied loop at the tip of the band is hooked

in the groove of the goldfinger and pulled around
the stomach (Figs 3.8A and B).
Fig. 3.8A: Pre-tied loops in position
Fig. 3.8B: Gentle withdrawal of Goldfinger

• The intra gastric balloon is inflated to 15 cc and

withdrawn to snugly fit the G-E junction. The
band is locked into place on the stomach just
below the inflated balloon to create a 15 cc pouch
(Fig. 3.9).
Fig. 3.9: Inflated balloon and locking of band
• The band is fixed anteriorly with 3-4 gastro-gastric

sutures. Staying above the lesser sac ensures
posterior fixation (Fig. 3.10).
• The band tube is withdrawn outside the peritoneal
cavity through the left mid clavicular trocar and
tunneled subcutaneously to emerge from the
epigastric port. The incision is given here to fix the
Fig. 3.10: Fixing of hand anteriorly
access reservoir to the abdominal wall fascia.

The tubing is connected to the reservoir, which is
filled with saline to remove any air bubbles inside
it. The reservoir is now fixed to the underlying
fascia with four balancing sutures all around.
• The epigastric incision is closed in layers to ensure
complete hemostasis.
POSTOPERATIVE CARE
• The patient undergoes a Gastrograffin swallow on
the day following surgery to see the band position,
the gastric pouch and presence of any leak.
• The patient is started on a liquid diet the day after

surgery, which is continued over the next Two
weeks. The quantity at any given time should be
about 100-150 ml taken over one hour. The
subsequent two weeks the patient is kept on a
semisolid diet and about four weeks following
surgery the patient can start taking normal diet.
The total caloric intake should remain between
800-1200 calories.
• Ambulation is encouraged on the day of surgery.
• All medication is given orally in crushed or liquid
form.
• The patient is discharged once oral intake of 1500
to 2000 ml/24 hrs is established.
FOLLOW UP
• All patients undergoing Bariatric surgical
procedures require long term follow up. Patients
with a gastric band need follow up for band
adjustment and monitoring of nutritional status.
The adjustment is performed on an outpatient
basis 6 weeks following surgery under radiological
guidance. Subsequent band adjustments are
performed by monitoring the patients’ weight
every four to six weeks.
• Nutritional status is monitored by evaluating the
CBC and Serum protein levels of patients’ every
3 months in the first year and every 6 months
thereafter.
COMPLICATIONS
• Laparoscopic adjustable gastric banding is
associated with early and late complications. The
overall incidence of complications following
adjustable gastric banding ranges between 2% to
7%, with a long-term re-operative rate of 16%.
• Early postoperative complications include – gastric
perforation, band system disconnection or balloon
perforation and port site infection. The incidence
of band slippage has significantly reduced after
the introduction of the pars flaccida approach.
• Late complications include – band erosion, pouch
dilatation, esophageal dilatation and failure to lose
weight.
RESULTS
• Laparoscopic adjustable gastric banding is consi-
dered a less morbid, simple and safe procedure.
The potential of adjustability and reversibility make
this procedure an attractive surgical option for
both the patient and the surgeon.
• The weight loss is slower compared to malabsorp-
tive and combined surgical procedures such as the
bilio-pancreatic diversion and gastric bypass. The
patients continue to lose weight over 2 to 3 years.
The mean excess weight loss is reported as 50%
to 60% from some regions and < 40% from others.
The failure rate is high with 15% to 20% patients
failing to lose weight.
• Prognostic factors are dietary habits and psycholo-

gical profile.
We have performed gastric banding in 57 patients
from Dec 2004 to April 2007. The BMI ranged from
34.5 to 65.3 kg/m2. The period of follow up was from
4 to 27 months. The period of hospitalization was two
to three days. There was no mortality and negligible
morbidity. Two patients required re-exploration.
One patient underwent relaparoscopy for band
replacement due to a fractured tube and one patient
required band removal due to band infection. The
patients on an average achieved 24.99% EWL (range–
5 to 71%). The patients reporting poor weight loss or
weight gain were predominantly sweet eaters.
This early result may also appear misleading as
weight loss with the gastric band continues over two
to three years and number of gastric bands place in
the first year were only about 10. With passage of
time this result may improve to match that reported
in literature.
LAPAROSCOPIC SLEEVE GASTRECTOMY

Surgical Principle
Laparoscopic sleeve gastrectomy (also called vertical
gastrectomy, greater curvature gastrectomy, parietal
gastrectomy, gastric reduction and even vertical
gastroplasty) is a relatively new Bariatric surgical
option for treating morbid obesity. The stomach is
restricted by dividing it vertically and removing more

than 85% of it. This possibly eliminates most Ghrelin
hormone production and helps to reduce the
sensation of hunger that people have. This part of the
procedure is irreversible. The remnant stomach is
tubular in structure and measures from 60 to 150 cc.
The gastric and pyloric innervation remains intact
preserving the functions of the stomach while
reducing the volume. It originally formed the
restrictive component of the bilio-pancreatic diversion
(with duodenal switch) malabsorptive procedure.
Recently the procedure was segregated into an
independent surgery in an attempt to decrease the
morbidity and mortality of high risk patients with
super obesity. It may not be long before the procedure
is offered as a primary restrictive treatment option
to patients with morbid obesity.
Steps of Operation
• The liver is retracted and the stomach examined
from GE junction to the pylorus.
• The nerve of Latarjet (anterior vagal trunk) is
identified as the crow’s feet at the pylorus and
dissection begins 6 to 8 cm proximal to this
landmark (Fig. 3.11). The vessels supplying the
greater curvature are divided using either
ultrasonic shears or high frequency bipolar devices
like ligasure up to the GE junction (Fig. 3.12).
• The stomach is now transected vertically 6 to 8 cm
from the pylorus using first the green (one) and
Fig. 3.11: Identification of crow’s feet (Anterior nerve of Latarjet)
Fig. 3.12: Division of vascular branches supplying greater

curvature of stomach
then blue (3-4) endostaplers (EndoGIA 60 mm,

Tyco, New Haven, CT, USA). The first endostapler
is fired in the direction of the lesser curvature
towards the crow’s feet.
• The anesthetist now passes a 32 Fr gastric bougie
into the stomach along the lesser curvature for cali-
brating the gastric tube. The subsequent endo-
staplers are fired fitted firmly against the bougie
to create a gastric volume of 60–120 ml (Fig. 3.13).
Fig. 3.13: Application of endostaplers around the bougie
• The gastric tube is checked for possible leaks using

the methylene blue test. The staple line is also
checked for bleeding points. The suture line may
be reinforced by under running non-absorbable
sutures or the use of bovine pericardial strips (peri

strips Dry, Synovis surgical Innovation, St. Paul,
MN, USA).
• The resected gastric segment is inserted into a
retrieval bag and removed by increasing the
diameter of one of the port sites to about 2.5 cm.
This port site is closed under vision using a port
closure needle.
• A drain is placed along the staple line (Fig. 3.14).
Fig. 3.14: Drain placement
• The oblique direction of all trocars precludes the

need for fascial closure.
Postoperative Care
• The patient undergoes a Gastrograffin swallow
on the day following surgery to see the volume
of the neo-stomach and to rule out any staple line
leaks.
• The patient is started on a clear liquid diet there
after, allowed 100-150 ml of fluids per hour and
usually discharged after another 48 hours.
• Postoperative dietary regimen is similar to that
followed by patients undergoing adjustable gastric
banding. The patient is on a liquid diet for initial
two weeks following surgery, followed by a soft
diet over the next two weeks which progresses to
a normal diet by 1 month following surgery.
Follow up
Follow up should be stringent and similar to that
required in any bariatric surgical procedure. This is
more so in case of the vertical gastrectomy due to the
potential for inadequate weight loss or weight regain.
Although this is true for all bariatric procedures, its
theoretical possibility increases with procedures that
do not have an intestinal bypass.
• Nutritional status is monitored by 6 monthly
evaluation of CBC and serum proteins.
• Weight record is maintained to monitor weight
loss and for timely intervention in the event of
inadequate weight loss or weight gain.
Complications
The incidence of complications for sleeve gastrectomy
are reported at <1% (Fig. 3.15). These include–Deep
vein thrombosis, non-fatal pulmonary embolus,
pneumonia, acute respiratory distress syndrome,
splenectomy, gastric leak and fistula, postoperative
bleeding, small bowel obstruction, death.
Results
On average, patients who undergo vertical gastrec-
tomy surgery experience a 60-80% loss of excess
weight. This weight loss allows significant improve-
ment in health and effectively “downstages” a patient
to a lower risk group. Once the patients BMI is lower
(35-40), they can return to the operating room for the
Fig. 3.15: Laparoscopic sleeve gastrectomy

“second stage” of the procedure, which can either be

the duodenal switch or a Roux-en-Y gastric bypass.
Our own experience with laparoscopic sleeve
gastrectomy is limited to ten patients over the last
two years. The BMI of these patients ranged between
66 and 81 kg/m 2 . The follow up is from 2 to 13
months. The initial results reveal no mortality, no
leaks, and one conversion requiring splenectomy,
almost negligible morbidity and average % EWL of
55%. One patient has started regaining weight and is
now scheduled for a second stage definitive
procedure.
BIBLIOGRAPHY
1. Angrisani L, Lorenzo M, Borrelli V. Laparoscopic adjustable
gastric banding versus Roux-en-Y bypass: 5-year results of a
prospective randomized trial. Surg Obes Relat Dis 2007; 3: 127-
32; discussion 132-3.
2. Baltasar A, Serra C, Perez N, Bou R, bengochea M, Ferri L.
Laparoscopic sleeve gastrectomy: a multi-purpose bariatric
operation. Obes Surg 2005; 15: 1124-8.
3. Brown W, Dixon JB, Brien PO. Management of obesity–the role
of surgery. Aust Fam Phy 2006; 35: 584-6.
4. Colquitt J, Clegg A, Loveman E, Royle P, Sidhu MK. Surgery
for morbid obesity. Cochrane Database Syst Rev 2005; 19:
CD003641.
5. Cottam D, Qureshi FG, Mattar SG, Sharma S, Holover S,
Bonanomi G, Ramanathan R, Schauer P. Laparoscopic sleeve
gastrectomy as an initial weight-loss procedure for high-risk
patients with morbid obesity. Surg Endosc 2006; 20: 859-63.
6. DeMaria EJ, Jamal MK. Laparoscopic adjustable gastric
banding: Evolving clinical experience. Surg Clin North Am 2005;
85: 773-87.
7. Favretti F, Segato G, Ashton D, Busetto L, De Luca M, Mazza
M, Ceoloni A, Banzato O, Calo E, Enzi G. Laparoscopic
adjustable gastric banding in 1,791 consecutive obese patients:
12-year results. Obes Surg 2007; 17: 168-75.
8. Frezza EE. Laparoscopic vertical sleeve gastrectomy for morbid
obesity. The future procedure of choice? Surg Today 2007; 37:
275-81.
9. Himpens J, Dapri G, Cadiere GB. A prospective randomized
study between laparoscopic gastric banding and laparoscopic
isolated sleeve gastrectomy: Results after 1 and 3 years. Obes.
Surg 2006; 16: 1450-6.
10. Kinzl JF, Schrattenecker M, Traweger C, Mattesich M, Fiala M,
Biebl W. Psychosocial predictors of weight loss after bariatric
surgery. Obes Surg 2006; 16: 1609-14.
11. Langer FB, Reza Hoda MA, Bohdjalian A, Felberbauer FX,
Zacherl J, Wenzl E, Schindler K, Luger A, Ludvik B, Prager
G. Sleeve gastrectomy and gastric banding: Effects on plasma
ghrelin levels. Obes Surg 2005; 15: 1024-9.
12. Micheletto G, Roviaro G, Lattuada E, Zappa MA, Mozzi E,
Perrini M, Lanni M, Francese M, Librenti MC, Doldi SB.
Adjustable gastric banding for morbid obesity. Our experience.
Ann. Ital. Chir. 2006; 77: 397-400.
13. Mizrahi S, Avinoah E. Technical tips for laparoscopic gastric
banding: 6-year’s experience in 2800 procedures by a single
surgical team. Am Jour Surg 2007; 193: 160-5.
14. Mognol P, Chosidow D, Marmuse JP. Laparoscopic sleeve
gastrectomy (LSG): Review of a new bariatric procedure and
initial results. Surg Tech Int 2006; 15: 47-52.
15. Naef M, Naef U, Mouton WG, Wagner HE. Outcomes and
complications after laparoscopic Swedish adjustable gastric
banding: 5-year results of a prospective clinical trial Obes Surg
2007; 17: 175-201.
16. Nguyen NT, Longoria M, Gelfand DV, Sabio A, Wilson SE.
Staged laparoscopic Roux-en-Y: A novel two-stage Bariatric
operation as an alternative in the super-obese with massively
enlarged liver. Obes. Surg. 2005; 15: 1077-81.
17. O’Brien PE, Brown WA, Dixon JB. Obesity, weight loss and
Bariatric surgery. Med Jour Aust 2005; 183: 310-4.
18. Provost DA. Laparoscopic adjustable gastric banding: an
attractive option. Surg Clin North Am. 2005; 85: 789-805.
19. Roa PE, Kaidar-Person O, Pinto D, Cho M, Szomstein S,
Rosenthal RJ. Laparoscopic sleeve gastrectomy as treatment
for morbid obesity: Technique and short-term outcome. Obes
Surg 2006; 16: 1323-6.
20. Sanchez-Santos R, Ruiz de Gordejuela AG, Gomez N, Pujol

J, Moreno P, Francos JM, Rafecas A, Masdevall C. Factors
associated with morbidity and mortality after gastric bypass.
Alternatives for risk reduction: Sleeve gastrectomy Cir Esp 2006
Aug; 80(2):90-5. Spanish.
21. Serra C, Perez N, Bou R, Bengochea M, Martinez R, Baltasar
A. Laparoscopic sleeve gastrectomy. A bariatric procedure with
multiple indications Cir Esp 2006; 79: 289-92.(Spanish).
22. Silecchia G, Boru C, Pecchia A, Rizzello M, Casella G, Leonetti
F, Basso N. Effectiveness of laparoscopic sleeve gastrectomy
(first stage of biliopancreatic diversion with duodenal switch)
on comorbidities in super-obese high-risk patients. Obes Surg
2006; 16: 1138-44.
CHAPTER 4
Pancreas Preserving
Duodenectomy
TD Yadav
INTRODUCTION
Pancreaticoduodenal resection is a well-accepted
procedure for periampullary malignancies. Local
resection of the ampulla has been advocated for
localized and benign looking lesions. The problem
area is when there is diffuse duodenal involvement,
i.e. adenomatous polyposis coli or there is diffuse
duodenal injury. Local resection is not possible in
most of them and pancreaticoduodenal resection has
its own procedure related significant mortality and
morbidity even in experienced hands. Pancreas
sparing duodenectomy (PSD) in these patients offers
an appropriate alternative. Even though duodenum
and pancreas share a common blood supply, duo-
denum can be resected without compromising
viability of pancreas. PSD was first described in 1995
to treat benign tumors of duodenum. Later, the
procedure has been classified into three types
(Fig. 4.1), depending upon the extent of resection
performed.
Type 1 represents subtotal duodenectomy that
preserves major and minor papilla; this has further
been divided into type 1a (where resection of
duodenum is done above the papilla) and type 1b
where duodenum is resected below the papilla. Type
2 entails leaving behind papilla on the pancreatic head
after a total duodenectomy. In type 3, the terminal
portion of bile duct and pancreatic duct are exposed
and anastomozed to an isolated loop of jejunum.
Pancreas Preserving Duodenectomy 57
Fig. 4.1: Classification of PSD
INDICATIONS
• Adenomatous polyposis coli,
• Villous adenoma,
• Isolated duodenal injury.
• Other benign tumors of duodenum.
PREOPERATIVE WORKUP
Routine preparation is required which is done for any
major surgery.
SURGICAL TECHNIQUES
Position of the Patient
Supine
Incision
Generous midline incision or standard right subcostal
incision.
Anatomical Considerations
Beneath the superior mesenteric vessels there is a
rudimentary mesoduodenum which is the embryolo-
gical remnant of the duodenal mesentery. This
mesentery contains blood vessels which supply
duodenum, head of the pancreas and proximal
jejunum. This mesoduodenum is better defined in the
infra-ampullary than the supra-ampullary region.
The C-loop of duodenum, head of pancreas and few
centimeters of proximal jejunum share a common
blood supply by the pancreaticoduodenal arcade.
The arcade is formed by anterior and posterior
branches of superior and inferior pancreaticoduodenal
arteries which make the anterior and posterior
pancreaticoduodenal arcades. This detailed anatomical
knowledge of this arcade has allowed surgeons to
conduct limited resections of the head of pancreas.
Kimura has found that in 70% of the cases, the
anterior inferior pancreaticoduodenal artery doesn’t
run on anterior surface but behind lower portion of
the pancreatic head. So it has been found that
posterior arcade is more consistent than anterior
arcade. The posterior and anterior branches of
inferior pancreaticoduodenal arteries (AIPDA and
PIPDA), in about 55% to 60% of cases man originate
along with the first arcade of jejunum.
Steps of Operation
• Hepatic flexure of colon is reflected and duode-
num and head of pancreas is mobilized extensively
(extended Kocher’s maneuver).
• Ligament of Trietz is divided and proximal 10 cm.
of jejunum is mobilized and transected after
dividing its mesentery (Fig. 4.2).
Fig. 4.2: Operative anatomy during PSD
• Distal transected and freed jejunum is transferred

to the right side of superior mesenteric vessels as
is done during pancreaticoduodenal resection.
• Third and fourth portion of duodenum are
detached from head of pancreas by dividing short
vessels supplying medial wall of duodenum
between suture ligatures (division of inferior

pancreaticoduodenal artery may be done at its
origin from superior mesenteric artery but it is not
always necessary.)
• Process is continued up to papilla.
• Papilla is externally marked either by palpation or
by passing small catheter through the cystic duct
after having performed, cholecystectomy (preope-
rative Endoscopic stenting of common bile duct
may alternatively be done in elective situations).
• Extraduodenal bile duct is transected around the
stent close to duodenum.
• Pancreatic duct bound to inferior aspect of lower
end of CBD is transected in the process and
intubated with 16 gauge intravenous catheter.
• Proximal to the papilla pancreas is densely adhered
to duodenum but a subserosal plane exists just
outside muscularis propria. Dissection is best
carried out in this plane up to duodenal bulb.
• All small vessels supplying the medial wall of
duodenum are ligated and divided meticulously.
• Alternatively duodenum may be divided at the
duodenal bulb and followed distally towards
papilla.
• Bleeding in this plane is minimal.
• Duodenum is transected 1.5 cm distal to the
pylorus at the duodenal bulb.
• If the minor pancreatic duct is recognized, it must
be suture ligated with 5-0 PDS; otherwise there is
a chance of pancreatic fistula in the postoperative

period.
• The mobilized proximal jejunum is passed in front
of the superior mesenteric vessels and end to end
anastomosis is done using single layer of inter-
rupted sutures with fine absorbable sutures.
• An ampullojejunostomy or pancreaticojejunostomy
is done using single or two layers of interrupted
sutures (5-0 PDS).
• No 16 suction drain is placed routinely in the right
subhepatic space and abdomen closed.
• Feeding jejunostomy is done in selective cases.
Closure
• Abdominal wound is closed in layers.
POSTOPERATIVE CARE
Strict input out put chart is maintained. Perioperative
antibiotic cover is given to all patients. Nasogastric
suction is required nearly for 4-5 days post-
operatively to counter a tendency of delayed gastric
emptying. Monitoring of drain fluid amylase level is
done on postoperative days 1,4 and 7. Drain is
removed if amylase level is normal and out put is less
than 100 ml per 24 hours and there is no evidence of
biliary or bowel leak. Nasogastric tube is taken out
when out put is less than 200 ml/day and abdomen
is soft. Oral diet may be started on day 7 or 8
depending upon the overall condition of patient.

Jejunostomy tube feeding is started on postoperative
day 1 if the patient is stable.
RESULTS
Till date authors have performed 7 pancreas sparing
duodenectomies; five were done for duodenal trauma,
one for duodenal dystrophy and one for heterotrophic
pancreas with massive upper gastrointestinal bleed.
There was one mortality. This patient had a duodenal
dystrophy and recurrent intestinal obstruction.
Unfortunately this was diagnosed late and patient was
found to have strangulation. On exploration there was
internal herniation with extensive bowel gangrene;
resection and anastomosis was done, but he died in
the postoperative period due to multi system organ
failure. Another patient had intra-abdominal bleed but
no source could be found on exploration. He recovered
well. None of the patients developed pancreatic or
biliary fistula.
BIBLIOGRAPHY
1. Chung RS, Church JM,vanStolk R. Pancreas sparing
Duodenectomy: Indications, surgical technique and results.
Surgery. 1995; 117: 254-9.
2. Kimura W. Surgical anatomy of the pancreas for limited
resection. Jour Hepatobiliary Pancreatic Surg 2000; 7: 473-79.
3. Nagai H. Configurational anatomy of the pancreas: Its surgical
relevance from ontogenetic and comparative-anatomical
viewpoints. Jour Hepatobiliary Pancreatic Surg 2003; 10: 48-56.
4. Yadav TD, Kaushik R. Pancreas sparing Duodenectomy for
trauma. Tropical Gastroenterology 2004; 25: 34-85.
CHAPTER 5
Transduodenal
Resection of
Ampulla
TD Yadav
INTRODUCTION
Ampullary neoplasms are uncommon and represent
less than 10% of periampullary tumors. Majority of
these tumors are adenocarcinoma but rarely
adenoma, hyperplasic polyps, neuroendocrine tumors
and neuroma may be found. The first ampullary
resection was performed by William Halsted in 1899
for ampullary carcinoma. Improvement in the outcome
of pancreaticoduodenal resection has led to a
decrease in the surgical indications for this procedure
by and large it is limited today for only benign
disease or in patients who are found not to be fit for
pancreaticoduodenal resection.
INDICATIONS
• Small benign looking lesions on endoscopy or
endoscopic biopsy
• Small benign appearing carcinoids
• Low grade neuroendocrine tumors
• Patients with adenocarcinoma who are not candi-
dates for major pancreaticoduodenal resection and
present with bleeding complications
PREOPERATIVE WORKUP
Since these patients are usually jaundiced, the
coagulation profile has to be corrected before surgery
and nutrition should be optimum.
Transduodenal Resection of Ampulla 65
SURGICAL TECHNIQUES
Supine.
Incision
Subcostal, bilateral subcostal or midline.
Anatomical Considerations
The ampulla is located in the posteromedial wall of
the second part of the duodenum. It is formed by the
confluence of the intradudenal bile duct (CBD),
terminal main pancreatic duct (PD). It is surrounded
by the muscular sphincter of Oddi, where the ducts
empty into the duodenum through the papilla of
Vater. The common channel formed by the confluence
of the CBD and PD, is present in approximately
half of the individuals. In the remaining, PD enters
separately into the duodenum and CBD through
papilla.
As a consequence of this anatomical relationship,
tumors of the ampullary region may arise from any
of the three epithelia (CBD, PD and duodenum) or
even the wall of the duodenum (connective tissue,
neuroendocrine cells). After resection of these tumors,
the biliary, pancreatic and gastrointestinal continuity
is reestablished.
Steps of Operation
• Thorough examination of the peritoneal cavity is
done to rule out metastatic disease.
• Extended Kocher’s maneuver is done and third
portion of the duodenum is mobilized to take it
in the operative field.
• Palpation of the papilla is done without opening
the duodenum.
• Retrograde cannulation of the papilla may be done
after doing cholecystectomy for the catheter to
serve as guide (Fig. 5.1).
Fig. 5.1: Retrograde cannulation of papilla
Two stay sutures are placed in the second part of

the duodenum and a generous longitudinal duodeno-
tomy is performed over the second and third parts

of duodenum.
• An outline of the resection line is marked with
needle tip cautery with about 1 cm margin around
the lesion (Fig. 5.2).
Fig. 5.2: Line of resection
• Stay sutures are taken on the duodenal mucosa

and excision started between stay sutures; the
depth of dissection must be in the submucosal
plane.
• Excision should always be started from lateral side
to the center of papilla in order to dissect the CBD
first (Fig. 5.3).
Fig. 5.3: Excision of papilla
• CBD and PD are then divided after applying stay

sutures proximally.
• Once the specimen is out, it is sent for frozen
section to examine the resection margins; if
positive for invasive carcinoma, pancreatico-
duodenal resection is recommended in patients
otherwise fit.
• A common channel is created between CBD and
PD using 5-0 PDS sutures and septotomy is
performed.
• Duodenal mucosa is reapproximated to the
common channel using 5-0 PDS or vicryl with
simple suturing technique (Fig. 5.4).
• Duodenum is closed in a transverse direction and

a closed suction drain is kept in the right upper
quadrant.
Fig. 5.4: Reapproximation of the

duodenal mucosa
POSTOPERATIVE CARE
• Patient is kept nil per orally and a nasogastric tube
is placed for active, passive aspiration of gastric
contents (for about 3-5 days depending upon the
overall condition of the patient).
• Strict input output, fluid and electrolytes moni-
toring is done.
• Nasogastric tube is taken out once the bowel
activity return and abdomen is soft.
• Oral diet can be started on postoperative day 5

depending upon the recovery of patient.
RESULTS
It is an uncommonly performed procedure. The post-
operative morbidity and mortality is much less
compared to pancreaticoduodenal resection.
Operative mortality in most of the series is zero.
Mean hospital stay is around 10 days. Mean operative
time and blood loss has been reported is approxi-
mately 169 minutes and 192 ml respectively. Different
postoperative complications include delayed gastric
emptying, CBD stricture, acute pancreatitis and
cholangitis. Resection margin is reported to be
positive in 11-60%, by different authors.
BIBLIOGRAPHY
1. Beger H, Treitschke F, Gansauge F, Harada N, Hiki N, Mattfeldt
T. Tumor of the ampulla of Vater. Arch Surg 1999; 134: 526-
32.
2. Clary B, Tyler D, Denatos P, Gottfried M, Pappas T. Local
ampullary resection with careful intraoperative frozen section
evaluation for presumed benign ampullary neoplasm. Surgery
2000; 127: 628-33.
3. Transduodenal local resection for periampullary neoplasm.
Bryan Clary, Theodore N, Pappas, Douglas Tyler. In Pancreatic
Cancer; Douglas B Evans, Peter W T Pisters, James L
Abbruzzese (eds): Springer, Newyork; 2002; 181-91.
CHAPTER 6
Median
Pancreatectomy
Adarsh Chaudhary
Amanjeet Singh
Azhar Pervaiz
Dinesh Singhal
DEFINITION
A surgical procedure removing middle segment of
pancreas preserving the proximal pancreas and
duodenum on the right and distal pancreas and spleen
on the left.
SYNONYMS
Middle pancreatectomy, central pancreatectomy,
pancreatic isthmectectomy, partial pancreatectomy,
segmental pancreatectomy, mesopancreatectomy.
INTRODUCTION
With improved imaging techniques, an increasing
number of patients with asymptomatic pancreatic
lesions are being diagnosed. Superficial lesions have
usually been enucleated and for lesions deep in
pancreatic parenchyma, either a pancreaticoduo-
denectomy or distal pancreatectomy and splenectomy
have been recommended.
Though the morbidity and mortality associated
with these procedures have decreased in the recent
times, still a significant number of patients develop
postoperative exocrine and endocrine pancreatic
insufficiency. Pancreaticoduodenectomy removes
around 30% to 40% of pancreatic parenchyma with
incidence of endocrine and exocrine deficiency
around 15% to 20%. The incidence is more in patients
with chronic pancreatitis reaching around 50%
Median Pancreatectomy 73
at 5 years. As most of islet cells are concentrated in

distal body of pancreas, the risk of diabetes is more
with distal pancreatectomy. Increasing interest in
organ preservation, has stimulated the need to
conserve as much functioning pancreas as possible and
hence the median pancreatectomy.
HISTORY
Guillemin and Bessot first described median pancrea-
tectomy for treatment of chronic pancreatitis. Letton
and Wilson used it for management of traumatic
pancreatic disruptions. The first reported use of this
procedure in pancreatic lesions was by Giovanni Serio
in 1984, in a patient with insulinoma of neck of pancreas.
Till date many more case series have been published.
ADVANTAGES
• Preservation of pancreatic parenchyma, reducing
the chances of exocrine and endocrine pancreatic
insufficiency
• Avoiding splenectomy and its inherent complica-
tions including immunosuppression and postsple-
nectomy infections
• Maintenance of upper gastrointestinal tract inte-
grity (which is lost after Whipple’s procedure)
INDICATIONS
• Small pancreatic lesions (< 5 cm)
• Benign (insulinomas, serous and mucinous

cystadenoma) and low grade malignant tumors
(nonfunctioning islet cell tumor, solid cystic –
papillary tumor) in pancreatic neck or body.
Role for median pancreatectomy is however still
controversial in as (Intra papillary mucinous
neoplasms) they are considered to be premalignant
by nature.
• Distal residual stump > 5 cm.
PREREQUISITES FOR MEDIAN PANCREATECTOMY

• Accurate preoperative diagnosis
• Intraoperative USG (preferable)
• Availability of intraoperative frozen section to
confirm the diagnosis and to achieve negative
resection margins
SURGICAL TECHNIQUES
Supine.
Incision
Either midline or bilateral subcostal (preferred)
Steps of Operation
• Initial abdominal exploration is performed first for
metastasis or other lesions.
• Synchronous pathology is ruled out.
• Kocherization of the duodenum is done.

• Assessment of the head of pancreas is made to
ensure that it is free of any lesion.
• Relationship of the tumor to superior mesenteric
artery (SMA) is assessed.
• Opening of lesser sac and separation of pancreas
from superior mesenteric vein (SMV) is done.
• Take off omentum from transverse colon.
• Divide gastrocolic omentum.
• Identify middle colic vein (MCV), which is then
traced to SMV. May require division of MCV.
• Division of gastrocolic venous trunk is done to
obtain optimal exposure of anterior aspect of SMV.
• Preparation of tunnel between SMV and neck of
pancreas as for PD.
• Division of lesser omentum, exposing hepatic, right
gastric and gastroduodenal artery.
• May require division of right gastric and
gastroduodenal artery to expose portal vein and
pancreatic neck lesions.
• Mobilization of splenic flexure of colon.
• Delineating pancreatic anatomy.
• Incising peritoneum along superior and inferior
margins of pancreas.
• Evaluate of the lesion by bimanual palpation.
• Endoscopic ultrasound is used to assess the lesion
and its relation to vascular structures and the main
pancreatic duct (MPD).
• Posterior dissection of pancreas is performed next.
Dissection plane being posterior and superior to
pancreas.
• Any large dorsal pancreatic artery is ruled out.

If present this may be the only supply to distal
segment and this becomes a contraindication for
median pancreatectomy.
• Ligation of small branches of splenic artery and
vein is done.
• Pancreatic parenchymal division is achieved using
diathermy or sharp division with scalpel.
• Frozen sections should be done to ensure negative
margins.
• Ligation of main pancreatic duct is done in head
part, and the proximal stump is closed using fine
sutures or stapler.
• Extent of resection – right limit is the gastroduodenal
artery and the left limit is at least 5 cm of pancreatic
parenchyma. If distal remnant is small (< 5 cm) and
soft – complete pancreatectomy is performed.
Reconstruction
• Roux-en-Y (45 cm limb) jejunal limb
• Retro colic
• End to side
• Duct to mucosa pancreaticojejunostomy (preferred
at our centre). Pancreaticogastrostomy has been
reported but criticized as the acid in stomach and
absence of enterokinase activity may prevent
activation of pancreatic enzymes, thus contributing
to pancreatic exocrine insufficiency.
• Hemostasis, drainage (optional) and closure
POSTOPERATIVE CARE
• Oral fluids allowed on second postoperative day.
• Drain fluid amylase sent on third postoperative
day. Drain removed if draining < 50 ml/day and
drain fluid amylase is normal.
• Usually discharged on postoperative day 4 to 7.
POSTOPERATIVE PANCREATIC FISTULAS

• Estimated rate in various series range from
0% to 54%.
• Mean incidence slightly higher than pancreatico-
duodenectomy.
• Fistula may be pure if from proximal part or
complex if from pancreaticojejunal side.
• Lower autodigestive potential as the enzymes are
not exposed to bile enzyme activation.
• Most fistula heal completely with conservative
management.
RESULTS
In last 3 years, 5 patients with tumors of the body
of the pancreas underwent median pancreatectomy in
our unit, which performs about 60 pancreatic
resections annually. There were four females and one
male (aged 32-55 years). Preoperative workup
included ultrasonography and CT scan of the
abdomen. Preoperative biopsy was not attempted, as
the lesions were deemed resectable. Perioperative
blood transfusion was not required in any patient.

All patients had uneventful postoperative course.
Mean length of postoperative hospital stay was
six days.
Histological examination revealed non-functional
endocrine tumors in two patients while three patients
had a serous cystadenoma. The resection margins
were free of disease in all patients and none of the
sections demonstrated features of malignancy. All
patients are doing well at follow up of 4-38 months
with no evidence of disease, none of them developed
diabetes postoperatively.
BIBLIOGRAPHY
1. Anand R, Negi SS, Sud R, Chaudhary A. Median
pancreatectomy: A report of three cases. Indian Journal of
Gastroenterology. 2006; 25: 88-9.
2. Central pancreatectomy for benign pancreatic pathology/
trauma: Is it a reasonable pancreas-preserving conservative
surgical strategy alternative to standard major pancreatic
resection? Johnson MA, Rajendran S, Balachandar TG, Kannan
DG, Jeswanth S, Ravichandran P, Surendran R Aus NZ Jour
Surg 2006; 76: 987–95.
3. Hines OJ, Reber HA. Median pancreatectomy: Do the risks
justify the effort? Jour Am Coll Surg 2000; 190: 715–6.
4. Iacono C, Bortolasi L, Serio G. Is there a place for central
pancreatectomy in pancreatic surgery? Jour Gastrointest Surg
1998;2: 509-17.
5. Rotman N, Sastre B, Fagniez PL. Medial pancreatectomy for
tumors of the neck of the pancreas. Surgery 1993; 113: 5325.
6. Sperti C, Pasquali C, Ferronato A, Pedrazzoli S. Median
pancreatectomy for tumors of the neck and body of the
pancreas. Jour. Am Coll Surg. 2000; 190: 711-6
7. Sugiyama M, Abe N, Ueki H, Masaki T, Mori T, Atomi Y.
Pancreaticogastrostomy for reconstruction after medial
pancreatectomy. J Am Coll Surg 2004; 199:163-5.
CHAPTER 7
Distal
Pancreatectomy
Sadiq S Sikora
INTRODUCTION
Pancreatic resections are formidable procedures as it
tests not only the skills of the surgeons but also the
decision making capability in the pre and intraope-
rative phases. Distal resections of the pancreas involve
removal of the distal pancreas with or without spleen;
the pancreas is transected to the left of the superior
mesenteric/portal vein depending upon the location
of the lesion. Although mortality of pancreatic
resections have dramatically decreased especially of
distal resections, the morbidity continues to be high,
ranging from 30% to 40%; pancreatic leak with intra-
abdominal sepsis, hemorrhage and fistula formation
being the major morbidity. The surgical technique and
the surgeon are considered important factors in the
outcome of these patients and thus in this chapter
salient features of the operative technique of distal
pancreatectomy are highlighted.
INDICATIONS
• Tumors:
i. Pancreatic tumors in the body and tail of the
pancreas: Adenocarcinomas and cystic tumors
ii. Neuroendocrine tumors of distal pancreas
iii. Functioning tumors of the pancreas
iv. Infiltration of pancreas due to tumors of the
stomach, splenic flexure of the colon, left renal
tumors
Distal Pancreatectomy 81
• Chronic pancreatitis (CP):

i. CP with malignancy
ii. CP with pseudocyst in the tail of pancreas
iii. CP with splenic artery aneurysm
• Benign cysts of the pancreas
• Trauma
• Distal external pancreatic fistula – posttraumatic or
postacute pancreatitis
PREOPERATIVE WORKUP
Patients should undergo a complete preoperative
work up including a complete hemogram, liver
function and renal function tests. Patients with
diabetes mellitus should have good glucose control
prior to surgery. Informed consent is taken and two
units of blood are cross matched for surgery.
In elective situations and planned surgeries,
pneumococcal and meningococcal vaccine is
administered prior to surgery in preparation for a
splenectomy.
SURGICAL TECHNIQUES
Position
Patient is placed in a supine position with head end
elevated. In obese or heavily built patients, a small
sandbag under the left lower chest should be placed
to facilitate exposure and dissection of the spleen.
Incision
The incision of choice of the author is a bilateral
subcostal incision (occasionally with an upper midline
extension – Mercedes benz incision). The other
incisions used are a L incision (long vertical limb with
a left subcostal extension upto the tip of 11th rib), or
a long midline incision depending upon the habitus
of the patient.
Steps of Operation
• After laparotomy, a thorough examination of the
peritoneal cavity is undertaken to identify peri-
toneal metastasis or liver metastasis.
• Bilateral costal margins are retracted by the use
of a Rochard or a Belghiti retractor. A good
sturdy retractor is a key in a smooth performance
of the surgery and is a critical requirement.
Exposure of the Pancreas

• The lesser sac is opened and the greater omentum
is divided along the greater curvature of the
stomach preserving the right gastroepiploic vessels
and the vascular arcade.
• The left gastroepiploic and short gastric vessels are
ligated and divided.
• The inferior border of the pancreas is defined
dissecting from the transverse mesocolon along the
body and tail of the pancreas by fine dissection.
• The splenocolic ligament is divided within

ligatures to release the splenic flexure of the colon
from the inferior pole of the spleen.
Retropancreatic Dissection
• The superior mesenteric vein (SMV) is identified
inferior to the neck of the pancreas and dissection
behind the neck of pancreas and anterior to the
SMV is performed and a retropancreatic tunnel
behind the neck of pancreas is developed.
• A blunt Kelly clamp is carefully guided in the
tunnel to exit at the superior border of the
pancreas and the pancreatic neck is looped with
a vascular loop or 6F feeding tube.
• Dissection is also performed in a plane posterior
to the body of pancreas behind the splenic vein to
a point upto the superior border of the pancreas.
Ligation of the Splenic Vessels

• Dissection is performed at the superior border of
the pancreas to identify the common hepatic artery.
• The lymphatic tissue and lymph nodes along the
common hepatic artery are dissected medially
towards the celiac axis.
• The left gastric and splenic arteries are identified
after completing the nodal clearance.
• The splenic artery is looped and divided within
double ligatures and suture transfixed.
Division of Pancreas
• The pancreas is then transected at the neck after
placement of stay sutures superiorly and infe-
riorly.
• The transection is performed either by electro-
cautery or harmonic scalpel at a point with
adequate margin from the tumor.
• Hemostasis from the proximal cut end of the
pancreas is achieved by fine 5.0 prolene sutures.
• The splenic vein and SMV junction is identified.
• Coronary vein is identified and divided within
ligatures.
• The splenic vein is looped and divided after
placement of vascular clamps; the cut end at the
SMV junction is closed with 5.0 prolene,
continuous suture.
• The specimen end of the splenic vein is transfixed
with a 2.0 prolene suture.
Splenopancreatectomy
• Once the vascular structures are ligated and
divided, the pancreas and the spleen is attached
only by its retroperitoneal attachments. The
pancreatico-splenectomy is performed by
dissecting in the avascular retroperitoneal plane
extending behind the spleen and the specimen is
dissected en-bloc including all the lymphatics and
nodes from the celiac group.
• The specimen is finally delivered after incising the

spleno-renal ligament.
Management of Pancreatic Stump

• The proximal cut end of the pancreas (head) can
be managed by several methods;
Suture Closure
After transection, small bleeders from the cut end are
meticulously sutured with 5.0 prolene to achieve
hemostasis.
The pancreatic duct is identified and the duct is
transfixed with 4.0 / 5.0 prolene suture.
The cut end of the pancreas is sutured with a
4.0 prolene continuous suture or with interrupted
4.0 prolene suture.
The cut end of the pancreas is finally wrapped with
a tongue of omentum or a falciform ligament flap.
A falciform ligament flap is rotated from the
abdominal wall after ligating the ligament close to the
umbilicus and mobilizing the falciform from the
anterior abdominal wall to obtain a long pedicled flap
to wrap the cut end of the pancreas.
Stapler Closure
In this method the pancreas is transected using the
EndoGIA stapler 45 mm or 60 mm; vascular (white)
cartridge to obtain a double row of staples occluding
the cut end of the pancreas and the pancreatic duct.
The cut end may be reinforced either by an

omental or a falciform ligament flap as described
above.
Pancreaticojejunal Anastomosis
Occasionally in patients undergoing resections for
chronic pancreatitis with dilated proximal duct along
with stones, the pancreatic duct in the head is opened
into the head and all the stones are removed.
A pancreaticojejunal anastomosis to a Roux loop
of jejunum is performed with 3.0/4.0 prolene
continuous suture.
The author prefers the suture closure method to
stapler as closure of the duct and the pancreatic end
can be done in a controlled manner under vision without
risk of hematoma in the gland or bursting of the gland
as has been described with stapler application.
Conventional Distal Pancreatectomy

• After exposure of the pancreas through the lesser
sac, the lieno-renal ligament is incised and the
spleen is mobilized medially.
• The spleen along with the body and tail of
pancreas is mobilized from lateral to medial side
by dissection in the retropancreatic avascular
areolar plane.
• The splenic artery is identified at the superior border
of the pancreas at its origin from the celiac axis.
• The artery is dissected, looped and divided within

ligatures.
• The left coronary vein is ligated at the superior
border of the pancreas.
• The superior mesenteric vein is identified and the
junction of splenic vein with SMV is defined.
• The splenic vein is dissected circumferentially
behind the neck of pancreas with adequate margin
from the offending lesion.
• The splenic vein is divided after placement of
vascular clamps.
• The cut end at the SMV junction is closed with 5.0
prolene, continuous suture.
• The specimen end of the splenic vein is transfixed
with a 2.0 prolene suture.
• The pancreas is then transected as described above
and specimen is removed.
Spleen Preserving Distal Pancreatectomy

• Spleen preserving distal pancreatectomy is usually
indicated in patients with benign tumors of the
pancreas, traumatic pancreatic fistula or benign
cysts of the pancreas.
• There are two techniques of spleen preserving
distal pancreatectomy;
i. In the first technique, the spleen preservation is
based on ligating the main splenic vessels and
preserving the vascularity of the spleen by the
collateral circulation from short gastric vessels.
• The salient features of this technique include

preservation of the gastroepiploic arcade, left
gastroepiploic and short gastric vessels and the
communicating vessel between the left gastro-
epiploic artery and splenic hilum.
• The splenic artery and vein are divided as
described above and the pancreas is transected at
the neck.
• The pancreas is dissected from medial to lateral
in the avascular plane past the tip of the tail of
pancreas.
• The splenic vessels are ligated and divided close
to the pancreas without disturbing the collateral
circulation in the hilum.
• The spleen is left undisturbed in its bed.
• During this procedure assessment of the viability
of the spleen has to be done at each step and if
there is any doubt splenectomy is performed.
ii. The second technique involves careful dissection of
the splenic vessels from the pancreatic body and tail
thus preserving the splenic vasculature to the spleen.
• The salient features of this technique are opening
the gastrocolic ligament to enter the lesser sac as
above preserving the gastroepiploic arcade, left
gastroepiploic and short gastric vessels.
• The peritoneal attachment at the lower border of
the pancreas is incised and the pancreas is
mobilized.
• Splenic vein is identified and dissected meti-

culously from the pancreas.
• The pancreas is dissected away from the veins in
the region of the neck and head.
• The splenic vein is dissected away from the
pancreas in the region of the body and tail by
suture ligating the small tributaries draining the
pancreas into the vein.
• The splenic artery is identified at the superior
border of the pancreas, looped and dissected
ligating the branches to the pancreas.
• Once the distal pancreas is mobilized and sepa-
rated from the vessels the pancreas is transected
with adequate margin from the lesion.
Drains
A single 24F portex tube drain is placed in the left
subphrenic space and brought out in the left flank
from a separate incision and anchored to the
skin.
Closure
Wound is closed in layers; midline wound with single
layer continuous No 1 prolene; transverse wounds
with No 1 prolene (or No 1 PDS) mass closure,
continuous all layers. Skin is closed with skin staplers
or 3.0 ethilon.
POSTOPERATIVE CARE
Vital parameters are monitored in the postoperative
period. Intravenous fluids are administered and
urinary output is maintained at > 50 ml per hour.
Electrolytes are monitored and replaced accordingly.
Antibiotics are continued in the postoperative period.
Routine use of perioperative octreotide is not
practiced by the author. Perioperative octreotide is
administered if the gland is soft and there is
unsatisfactory closure of the pancreatic stump based
on the operative surgeons’ discretion. Drain output
is monitored for the amount and nature i.e. blood or
clear pancreatic juice. Drain fluid amylase is done on
day 3; if drain fluid amylase is low then drain is
removed if discharge is serous and < 30 ml per
24 hours. If drain fluid amylase is high (> 3 times the
serum amylase), serial values are performed until the
above mentioned criteria for drain removal are met.
Oral fluids are started after 36-48 hours.
BIBLIOGRAPHY
1. Kimura W, Han I, Furukawa Y, et al. Appleby operation for
carcinoma of the body and tail of the pancreas.
Hepatogastroenterology 1997; 44: 387–93.
2. Kleeff J, Diener MK, Z’graggen K, Hinz U, Wagner M,
Bachmann J, Zehetner J, Mu¨ller W, Helmut Friess H, Bu¨chler
MW. Distal Pancreatectomy risk factors for surgical failure in
302 consecutive cases. Ann Surg 2007; 245: 573–82.
3. Knaebel HP, Diener MK, Wente MN, Bu¨chler MW, Seiler CM.
Systematic review and meta-analysis of technique for closure
of the pancreatic remnant after distal pancreatectomy. Brit Jour
Surg 2005; 92: 539-46.
4. Liu B. Modified Appleby operation in treatment of distal
pancreatic cancer. Hepatobiliary Pancreatic Dis Int 2003; 2: 622-
5.
5. Rodríguez JR, Madanat MG, Healy BC, Thayer SP, Warshaw
AL, Carlos Fernández-del Castillo C. Distal pancreatectomy
with splenic preservation revisited. Surgery 2007; 141: 619-25.
6. Singh G, Artinyan A, Jabbour N, Mateo R,Matsuoka L, Sher
L, Genyk Y, Selby R. Extended pancreatectomy with resection
of the celiac axis: The modified Appleby operation. Am Jour
Surg 2006; 192: 330–5.
7. Sledzianowski JF, Duffas JP, Muscari F, Suc B, Fourtanier F.
Risk factors for mortality and intra-abdominal morbidity after
distal pancreatectomy. Surgery 2005;137: 180-5.
8. Strasberg SM, Drebin JA, Linehan D. Radical antegrade
modular pancreatosplenectomy. Surgery 2003; 133: 521–7.
9. Strasberg SM, Linehan DC, Hawkins WG. Radical antegrade
modular pancreatosplenectomy procedure for adenocarcinoma
of the body and tail of the pancreas: Ability to obtain negative
tangential Margins. Jour. Am Coll Surg 2007; 204: 244–9.
CHAPTER 8
Biliary Surgery in
Portal Hypertension
Richa Lal
Avinash Kumar Tang
Vinay Kapoor
INTRODUCTION
Biliary surgery in the setting of portal hypertension
(PHT) is a challenging task and demands extreme
surgical expertise, maximum preoperative optimi-
zation of liver functions, and continued monitoring
and support of liver function postoperatively.
A multidisciplinary approach comprising a team of
skilled biliary surgeon, experienced anesthetist,
intensivist, hepatologist, intervention radiologist with
a good blood bank support, is the key to successful
outcome.
Patients for biliary surgery having portal hyper-
tension can be categorized in two basic pathophysio-
logical groups, one with the background of extra-
hepatic portal vein obstruction (EHPVO) and the
second group with the presence of chronic liver
disease (CLD) or cirrhotic portal hypertension (CPH).
This chronic liver disease may be a consequence of
long standing biliary obstruction or an underlying
medical etiology like alcohol, viral or an autoimmune
insult.
The primary concern in extrahepatic portal vein
obstruction relates to the presence of cavernoma in
the hepatoduodenal ligament which make access to
the biliary system tedious and fraught with risk of
life-threatening hemorrhage. The dominant concern
in the chronic liver disease patients are also related
to the presence of collaterals but they also have
significant impairment of liver functions.
Biliary Surgery in Portal Hypertension 95
• Serious attention must be paid to preoperative

optimization of liver functions. This includes:
i) control of ascites, ii) correction of coagulation
defects, iii) optimization of nutrition iv) control of
cholangitis v) reduction of portal pressures vi) use
of hepatoprotective agents.
• Relatively little preparation is required for a
Child’s A grade patient. If the preoperative liver
function is Child’s C grade, efforts must be made
to bring it up to Child’s B grade.
In general, intraoperative difficulties relate to;
• Difficulty of access to the biliary tree because of
collaterals and thickening of tissue planes due to
chronic venous congestion
• increased blood loss because of high pressure
venous collaterals and coagulopathy; and
• Sometimes a distortion of the hepatic hilar
anatomy because of atrophy-hypertrophy complex.
The commonly performed biliary procedures in
the setting of portal hypertension are: i) cholecys-
tectomy, ii) benign biliary stricture repair,
iii) choledochal cyst excision and iv) biliary-enteric
anastomosis for portal biliopathy strictures.
Meticulous technique, i.e. avoiding of blunt dis-
section, suture ligation and division or suture trans-
fixation before division are required to be practiced.
A diathermy, a harmonic scalpel or an argon beam
coagulator are useful aids to the surgeon. Appropriate
replacement of blood, fresh frozen plasma and platelets
needs to continue intraoperatively. It is important to

prevent hypothermia and acidosis which tend to
aggravate coagulopathy. Access to the biliary tree is
also facilitated by preoperative percutaneous placement
of biliary catheters and intraoperative ultrasound.
CHOLECYSTECTOMY IN PORTAL HYPERTENSION

• Cholecystectomy is the commonest biliary opera-
tion performed in the setting of portal hypertension.
It is estimated that the frequency of gallbladder
disease in patients with cirrhotic portal hypertension
is 2-5 times higher than the non-cirrhotics. The factors
implicated in this increased frequency have been
hypersplenism, increased estrogen levels, increased
intravascular hemolysis, impaired gallbladder
motility and emptying. Patients with extrahepatic
portal vein obstruction also have an increased
incidence of gallstones (usually pigment) because
of hemolysis related to hypersplenism.
• Cholecystectomy in the presence of PHT is a diffi-
cult exercise. On the whole, patients with cirrhotic
portal hypertension undergoing cholecystectomy
exhibit the trends of older age, impaired liver
function, higher blood loss and higher mortality.
• The relevant issues here are: i) the incidence of gall
stones in portal hypertension ii) specific technical
difficulties, do’s and don’ts iii) the technical
modifications suggested iv) the decision between
open vs. laparoscopic cholecystectomy.
Position
• Supine
Incision
• Subcostal, Midline or Right para median.
Steps of Operation
Similar to the steps of operation described for routine
Cholecystectomy (see Volume 1 of the book) with
additional considerations and modifications as
mentioned in this chapter.
• The technical difficulties relate to the presence of
collaterals in the Calot’s triangle and in the gall
bladder bed. Thickening and fibrosis because of
chronic venous congestion together with colla-
terals makes the Calot’s triangle anatomy unclear
and attempts to control troublesome bleeding
during Calot’s triangle dissection predisposes to
risk of inadvertent bile duct injury.
• To circumvent problems related to unclear Calot’s
triangle anatomy and collaterals in the gallbladder
bed and in the Calot’s triangle, subtotal cholecys-
tectomy has been recommended in the setting of
portal hypertension. Subtotal cholecystectomy
refers to the technical modification wherein, the
gall bladder is opened at a convenient site which
is usually the fundus and the contents are
evacuated. The gallbladder is excised using a
cautery or harmonic scalpel leaving in situ the wall

of the gallbladder, directly in contact with the liver
and Calot’s triangle. (see volume 1 of the book)
The hemostasis along the cut edges of the remnant
gallbladder may be secured by continuous
interlocking hemostatic suturing. No attempt is
made to identify the structures within the Calot’s
triangle. The cystic duct is oversewn from within
the gallbladder remnant.
• The peritoneal cavity is drained for 24-48 hours
to monitor for postoperative bleeding and to pre-
vent wound dehiscence on account of exacerbation
of ascites.
• Laparoscopic cholecystectomy in these patients
ought to be performed with extreme caution by
an experienced surgeon. The specific technical do’s
and don’ts while performing laparoscopic
cholecystectomy in the setting of cirrhotic portal
hypertension are:
i. the epigastric port needs to be positioned to the
right of the midline to avoid falciform ligament
and its dilated vessels.
ii. the pressures for creating pnuemoperitoneum are
lowered as this is believed to minimize the
ischemia-reperfusion injury to liver.
iii. Extreme caution has to be exercised in observing
hemostasis.
iv. Laparoscopic subtotal cholecystectomy may be
resorted to in case of difficult Calot’s triangle
anatomy.
v. There should be low threshold for conversion.

vi. Adjustment of placement of telescopic port needs
to be done in case of distortion of hilar anatomy
because of atrophy-hypertrophy.
A successful laparoscopic cholecystectomy has
been reported to have advantages over open surgery
in terms of fewer complications like wound infections,
ascites and respiratory tract infections.
SURGERY FOR COMMON BILE DUCT STONES

• Technical problems, difficulties and their manage-
ment remains the same as discussed above under
the heading of cholecystectomy and subsequently
under the heading of benign biliary stricture.
• The commonly performed procedures include
i. endoscopic sphinterotomy and stenting
ii. choledocholithotomy and t tube drainage
iii. a drainage procedure i.e., choledochoduo-
denostomy or transduodenal sphinteroplasty
• Steps of operation for each procedure have
already been detailed in vol.1 of the book.
• Precautions which need to be followed during
endoscopic interventions are out of preview of this
book. However one most remember that if due
care is not taken, a sphincterotomy may cause
hemobilia or bleeding from the site which may be
difficult to control.
BENIGN BILIARY STRICTURE REPAIR IN PHT

• The incidence of development of portal hypertension
in patients with benign bile duct stricture has been
reported as 15% to 20%.
• The cause of portal is either secondary biliary
cirrhosis or less commonly portal vein injury
concomitant with biliary injury.
• Prolonged biliary obstruction, repeated episodes
of cholangitis and prior multiple unsuccessful
attempts at stricture also disposes to secondly
biliary cirrhosis.
• Hepaticojejunostomy in cirrhotic portal hyper-
tension is associated with considerable morbidity
and an operative mortality as high as 10% to 23%.
The technical difficulties are related to the presence
of dense adhesions in the subhepatic space because
of previous surgical intervention as well as high
pressure venous collaterals.
• Percutaneous balloon dilatation has therefore been
suggested, if feasible in these patients as an
alternative to surgical interaction.
• The various surgical options are :
i. Prior portosystemic shunt followed by
hepaticojejunostomy several weeks later or
concomitant shunt with hepaticojejunostomy.
ii. An extracorporeal veno-venous (portal vein
to axillary/femoral vein) bypass which
provides a temporary portasystemic shunt
thereby allowing a 1-stage repair of the
stricture.
iii. A direct hepaticojejunostomy without a prior

portosystemic shunt.
iv. Transjugular intrahepatic portosystemic shunting
followed by stricture repair.
v. Liver transplantation for end stage biliary
cirrhosis and very high stricture.
• The management strategy needs to be tailored
according to the merits of an individual case.
• A preoperative biliary drainage (for three to six
weeks) does facilitate optimization of liver function
in patients of cirrhotic portal hypertension and
biliary stricture.
• The child’s status of the patient needs to be
reassessed after three to six weeks of adequate
biliary drainage and control of cholangitis.
• Prior to stricture repair, PTBD catheter need to be
advanced towards the liver hilum to assist in the
identification of the ducts intraoperatively.
• Low strictures with favorable anatomy may be
approached directly without a prior PSS.
Intraoperatively, care is taken to suture transfix or
ligate tissues all along the dissection. Percuta-
neously placed biliary stents and intraoperative
ultrasound facilitate access to the bile duct. It is
advisable to direct the dissection directly on to the
base of the quadrate lobe which is a relatively
virgin area without much peripheral dissection.
However, the approach may need to be revised
according to the status of adhesions and
collateralization at exploration. The surgeon

should be mentally prepared to retract if there is
troublesome bleeding at any stage of dissection in
the hepatoduodenal ligament. It would then, be
preferable to revert to making a shunt at this stage
rather than persist with risky dissection in the
hepatoduodenal ligament. The repair of biliary
stricture is electively re-attempted following six
months of portal decompression while the patient
has a percutaneous biliary drainage catheter in
place.
• High strictures (type 4) are more likely to be
complicated with torrential hemorrhage and hence
the surgical management ought to be staged as a
portosystemic shunt first followed by stricture
repair.
• The shunt procedures performed in this setting
have been those where the vascular anastomosis
is placed away from the hilum, i.e. a proximal
splenorenal or a mesocaval shunt.
• Benign biliary stricture with portal vein throm-
bosis and cavernoma formation is a more definite
indication for portosystemic shunts prior to
attempting stricture repair. This scenario differs
from the cirrhotic portal hypertension in that these
patients tolerate a portosystemic shunt better with
nearly no risk of postshunt hepatic decom-
pensation. However portal vein cavernoma pose
a greater technical difficulty and risk of bleeding.
CHOLEDOCHAL CYST AND

PORTAL HYPERTENSION
• Portal hypertension in choledochal cysts may be
secondary biliary cirrhosis, portal vein thrombosis
because of recurrent cholangitis and pyeliphlebitis
or rarely due to compression of the portal vein by
the cyst itself.
• The predisposing factors are delay in presentation
and multiple prior episodes of cholangitis or a
prior internal drainage procedure with persistent
cystolithiasis and cholangitis. Biliary cirrhosis may
develop in the first few months of life in patients
with infantile choledochal cysts.
• A biliary drainage procedure prior to definitive
surgery is likely to helpful. This may be achieved
either by percutaneous transhepatic route or by a
surgical T-tube drainage of the cyst.
• Definitive surgery should be planned 3-6 months
after a biliary drainage procedure.
• If the total cyst excision is not considered to be
safe, partial excision of the cyst leaving behind the
posterior and medial walls in situ should be
considered. The pancreatic end of the cyst is
closed from within the cyst, and a Roux-en-Y end
to side choledochojejunostomy is made near the
confluence. The remnant mucosa on the posterior
and the medial walls of the cyst is than cauterized
and the hemostasis along its free edge ensured
with continous interlocking suture.
• If even partial cyst excision is not feasible,

conscious decision should to be taken to abandon
attempts at cyst excision. In patients with relatively
good child’s status (Childs’ A or early B), a porto-
systemic shunt is performed. This is combined with
a T-tube external drainage of the cyst or a cyst
internal drainage as a temporizing procedure. The
excision of choledochal cyst is electively reattemp-
ted following 6 months of portal decompression.
• In end stage liver cirrhosis it is better to opt for
an internal drainage as a temporizing procedure
to relieve biliary obstruction with liver transplan-
tation as the eventual definitive treatment.
PORTAL BILIOPATHY
• Portal biliopathy refers to morphological changes
in the biliary tree in the presence of portal
cavernoma. Although portal biliopathy is seen in
80% to 93% of patients with extrahepatic portal
vein obstruction, intervention (whether surgical or
nonsurgical) is indicated only for “symptomatic”
biliopathy. “Symptomatic” biliopathy in the form
of persistent cholestatic jaundice and/or cholangitis
is seen in 5% to 18% patients only.
• The technical difficulties in accessing the biliary tree
surgically in portal biliopathy are related to
(i) portal cavernoma, (ii) the site of biliary
obstruction being multiple and high often
extending proximal to the hilum which makes

access to the extrahepatic part of left and right
ducts difficult.
• The approach to portal biliopathy would be gover-
ned by:
(i) type of symptoms
(ii) cholangiographic anatomy (level of stricture,
associated choledocholithiasis or hepatico-
lithiasis), and
(iii) the venous anatomy of the splenoportal axis.
• The treatment strategy of portal biliopathy include:
(i) Emergent biliary decompression (either
percutaneous or endoscopic) in patients with
cholangitis. This is combined with endoscopic
extraction of bile duct calculi, if present.
(ii) If on assessment the venous anatomy of the
splenoportal axis, is found to be shuntable, a
portosystemic shunt either a splenorenal shunt
or a mesocaval shunt is performed. An
effective PSS alone has been documented to
relieve symptoms due to portal biliopathy in
as many as 50% to 70% of patients by
decompressing the portal cavernoma.
Surgical access for further bilioenteric anastomosis
in patients with persistent symptomatic biliary
obstruction despite a PSS, becomes less hazardous
with prior portal decompression.
• For patients who continue to have symptomatic
biliary obstruction despite a PSS, further decision
depends on the cholangiographic anatomy.
(i) For a stricture which would allow surgical

access to proximal extrahepatic right and left
ducts, a Roux-en-Y biliary-enteric anastomosis
is planned six months after a PSS.
(ii) For strictures extending proximally into the
intrahepatic ducts, a nonsurgical approach
(usually a combination of percutaneous and
endoscopic dilatation and stenting) is adopted.
• If the surgical autonomy, on the other hand, does
not favour a shunt, further approach is dependent
up on the cholangiographic anatomy.
(i) For high strictures extending proximal to the
porta, the approach would be nonsurgical
entailing a combination of endoscopic and
percutaneous intervention.
(ii) For strictures with a favorable anatomy, a
surgical biliary enteric anastomosis is planned.
Biliary-enteric drainage without a prior PSS
however may be a very hazardous procedure
technically in these patients. The surgeon must
be prepared to retract before hemorrhage
becomes life threatening. In such a situation,
one should opt for nonsurgical treatment.
Patients with a successful biliary enteric
drainage without a prior PSS are at risk of
recurrent symptoms on long term follow up
because of persistence of high pressure
paracholedochal and epicholedochal collaterals.
• It is once again emphasized that portosystemic

shunts have a very significant role to play in
management of symptomatic portal biliopathy in
terms of:
(i) Relieving biliary obstruction in some patients
(ii) In allowing safe biliary-enteric anastomosis in
others and
(iii) Ensuring good long term outcome following
biliary-enteric anastomosis.
Increased postoperative morbidity in patients
undergoing biliray surgery with portal hypertension
is related to -
• Exacerbation of ascites which predisposes to
wound dehiscence and poor wound healing
• Sepsis: In the form of infected ascitic fluid, surgical
site infection and respiratory tract infection.
Jaundiced patients are more susceptible to infec-
tions which is partly attributed to poor Kupffer cell
function and ascitic fluid serves as a good culture
medium for the growth of microorganisms
• Decompensation of liver function, and
• Upper gastrointestinal or surgical site bleeding.
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9. Perakath B, Sitaram V, Mathew G, Khanduri P. Post
chole-cystectomy benign biliary stricture with portal
hypertension: Is a portosystemic shunt before hepaticoje-
junostomy necessary? Ann Roy Coll Surg Eng 2003; 85: 317-
20.
10. Rao KLN, Chowdhary SK, Kumar D. Choledochal cyst
associated with portal hypertension. Pediat Surg Int 2003; 19:
729-32.
11. Sedgwick CE, Poulantzas JK, Kune GA. Management of portal
hypertension secondary to bile duct strictures: Review of 18
cases with splenorenal shunt. Ann Surg 1966; 163 : 949-53.
12. Vilbert E, Azoulay D, Aloia T, Pascal G, Veilhan L-A, Adam
R, Samuel D, Castaing D. Therapeutic strategies in
symptomatic portal biliopathy. Ann Surg 2007; 246: 97-104.
CHAPTER 9
Portacaval Shunts in
the Treatment of
Portal Hypertension
RA Sastry
Vibha Varma
INTRODUCTION
• Patients with variceal bleeding are increasingly
being managed by medical gastroenterologists and
interventional radiologists today and surgeons in
training therefore, have very little exposure to
patients with bleeding varices. Interest in portal
hypertension is thus on the decrease amongst
surgeons, with the exception of transplant
surgeons. Liver transplantation is being recognized
by many as the only definitive treatment in
approach to complicated cirrhosis and portal
hypertension, with use of TIPS during waiting
period.
• Contrary to the above, the authors maintain that
surgical portal decompression still has a definite
place in the management select patient’s i.e.
• In places where liver transplantation is still not
available,
• In places where non-cirrhotic portal
hypertension is common; especially in children
of growing age, who are generally in good
health, with normal liver function,
• In the economically challenged patients who
prefer a one-time definitive treatment,
• In patients with non-cirrhotic portal fibrosis and
• In the secondary prophylaxis against bleed in
early cirrhotics with good liver function parti-
cularly in patients who do not have ready access
to endoscopic and percutaneous treatments.
Portacaval Shunts 111
• ‘Portosystemic shunt’ includes all types of

anastomosis of a vein in the hypertensive portal
venous circulation to one in the low-pressure
systemic circulation and it can be selective or
central (partial or total).
• ‘Portacaval shunt’ on the other hand, specifies an
anastomosis between the inferior vena cava and
the portal vein, distal to the confluence of superior
mesenteric and splenic veins.
• The advantage of a total shunt as portacaval shunt
is that the hemorrhage is arrested in about 95%
of cases but at a price of 40% incidence of hepatic
encephalopathy.
• In emergency situations when bleeding cannot be
controlled by less invasive means and facilities for
TIPS are not available, a portacaval shunt may be
life-saving and encephalopathy may only be a
secondary consideration.
• Although consistently good results have been
shown by selected centres, the results of portacaval
shunt could not be reproduced by other centres,
the main concern being postoperative encephalo-
pathy.
• The concept of “surgical rescue” is still valid but
for the challenge in the past few years from the
TIPS. Data however indicate that TIPS may have
a high stenosis rate (>50%) and up to a 30% rate
of encephalopathy.
• To reduce the incidence of postoperative
encephalopathy and ascites, side to side portacaval
shunts were developed. Although the incidence of

ascites could be brought down, encephalopathy
continued to be the major source of morbidity.
• To reduce the unacceptable rates of encephalo-
pathy, 8-mm H-graft portacaval shunts (HGPCS)
which functions as a partial shunt, have been tried
and a recent study has favored this kind of partial
shunt over TIPS.
• Feasibility of a portacaval shunt necessitates,
• A patent portal vein and IVC
• A patient with good liver function
• A dire necessity to arrest hemorrhage and
• A surgeon who has high-volume experience
with portacaval shunts and measures to reduce
hepatic encephalopathy.
INDICATIONS FOR PORTACAVAL SHUNT

Variceal Bleed in Cirrhotics
Acute Variceal Bleed
• Failure of nonsurgical treatment
• Emergency Portacaval shunt normalizes the
portal pressure immediately and is an
acceptable choice in high volume centres
because it effectively decompresses portal
venous system when control of bleeding is the
priority and is rapidly constructed.
• Splenectomized patients
Primary Prophylaxis
No role for portacaval shunt in primary prophylaxis.
Secondary Prophylaxis
• Patients with child’s A or early child’s B cirrhosis,
not actively consuming alcohol, not elderly or
medically unfit, benefit from shunt surgery the
most. Portacaval shunt is more effective than
endoscopic measures in reducing variceal rebleed,
even though there may not be an improvement in
survival.
• Splenectomized patients or unsuitable venous
anatomy for splenorenal shunt.
• Bleeding ectopic varices – stomal varices, portal
hypertensive colopathy, small bowel varices and
rarely uncontrolled hemorrhoidal bleeding
Intractable Ascites
• A side to side portacaval shunt (SSPCS) is
preferred.
Budd-Chiari Syndrome
• Again a side-to-side portacaval shunt is preferred
when the obstruction is confined to hepatic
veins and there are no cirrhotic changes in the
liver.
PREOPERATIVE PREPARATION
Apart from routine tests for diagnosing portal
hypertension, specific evaluation before shunt surgery
includes:
• Child’s scoring
• Good clinical examination
• Liver function tests
• Ultrasound examination of abdomen
• Color Doppler study of splenoportal axis, hepatic
veins, IVC and portal venous flow studies
• Selective celiac or superior mesenteric angio-
graphy with emphasis on venous phase if
Doppler study is inadequate or inconclusive
• Anatomy and patency of IVC and portal vein
and its tributaries are assessed.
• Thrombosis of PV or IVC is contraindication
for PCS.
• Partial thrombosis or recanalized vein is also
strong relative contraindication.
• Risk of shunt thrombosis is very high under
these circumstances.
• Hepatic veins are visualized to diagnose hepatic
venous outflow tract obstruction.
• In patients with Budd Chiari Syndrome (BCS)
• Liver biopsy – for prognosis and for deciding
treatment option
• Cirrhosis is a poor prognostic indicator for
survival.
• In the presence of cirrhosis – liver transplant

is treatment of choice.
• Side-to-side portacaval shunt(SSPCS) for
non-cirrhotic patients.
• IVC venography especially for pressure
measurements
• To rule out associated IVC block
• IVC pressure > 20mmHg or IVC / PV
pressure gradient of < 10 mmHg precludes
SSPCS because of high chances of shunt
thrombosis.
• Bowel wash and preparation with luminal
antibiotics (Neomycin) is mendatory to avoid
postoperative encephalopathy.
END TO SIDE PORTACAVAL SHUNT

Position on Table (Fig. 9.1)
• Supine position with right side elevated by 20° to
30°
• Right arm suspended/supported in front of the
patient
• Table broken at the level of costal margin
• Body placed level on central part of the table in
a head down position
Incision
• Long right subcostal incision
• Two finger breadths below costal margin
• From left of midline to right flank
Fig. 9.1: Patient position
• Right thoracoabdominal incision is another option;

but is associated with more incidence of chest
complications and pleural effusion.
• Meticulous hemostasis should be achieved while
opening the abdomen.
• Intraabdominal adhesions are ligated and divided
carefully, as they may contain collaterals.
Steps of Operation
• Exposure is achieved by systematic and measured
dissection.
• Portal venous pressure is measured before and
after shunting to determine the effectiveness of
shunt. This is done by direct puncture with a 20G
needle attached by sterile tubing to a transducer.
Fig. 9.2: Approximation and suture application – IVC and PV
• Porta hepatis is approached from the periphery.

• From above and below.
• From right and left.
• Hepatic flexure is mobilized and retracted down
with retractor placed over a swab.
• It is important to preserve the umbilical vein in the
falciform ligament in order to preserve the only
route for retrograde flow of portal blood and for
hepatic sinusoidal decompression postoperatively
and avoid consequent intractable ascites.
• Liver is reflected cranially with a broad blade
retractor placed on the under surface at the level
of gall bladder.
• Duodenum is Kocherized generously. Posterior
peritoneum is thick, vascular and edematous and
is divided carefully with a combination of cautery
and ligatures.
• Use of table retractors with multiple blades is useful

• Retractors on superior aspect are for liver and
gall bladder.
• Medially and towards the left for stomach and
duodenum.
• Inferiorly for the colon.
• Peritoneum overlying IVC is thick; it is lifted off
IVC and incised with sharp dissection
• Two thirds of anterior circumference of IVC
should be dissected for end to side shunt.
• Free edge of lesser omentum is dissected to
mobilize the portal vein
• CBD and HA are identified; mobilization is not
mandatory.
• Portal vein is approached from posterolateral
aspect of free edge of lesser omentum.
• Patient is rotated 20° to 30° to the left.
• Lymph nodes, lymphatics and fatty connective
tissue which obscure the portal vein are divided
and ligated for proper exposure.
• Accessory or replaced right hepatic artery arising
from SMA if present is on the posterolateral aspect
of CBD and it should be preserved.
• Portal vein is mobilized throughout its entire
extent
• Above, up to its bifurcation and entry into the
liver
• Inferiorly, behind pancreas where its formation
by union of SMV and splenic vein is visualized.
• Vein is mobilized circumferentially at midpoint

gently and slowly.
• Vessel loop is drawn around PV after all the
adventitial tissue is dissected free and all small
tributaries ligated and divided.
• Occasionally prominent caudate lobe of liver poses
problems in approximating the upper portion of
PV and IVC but a careful upward retraction of
caudate lobe is usually sufficient (Fig. 9.3).
• Occluding Satinsky clamp is placed on
anterolateral surface of IVC, approximately
30 degree to the left of midline.
• Segment of IVC is drawn into the jaws of Satinsky
with a Debakey dissector to make a window.
A button of vena cava, approximately three
fourths of the diameter of the compressed end of
the portal vein is excised to avoid a discrepancy
in sizes.
• 4-0 vascular suture is inserted at midpoint of right
side of window to retract it away.
• Potts clamp is placed on portal vein as low as
possible at the junction of SMV and splenic vein
• Second clamp is placed on PV close to the
bifurcation.
• Vein is divided obliquely to increase the caliber
of anastomosis and to avoid kinking.
• Portal vein stump towards the liver is ligated or
closed with a vascular suture and allowed to
retract into the hilum of liver.
• Lumen of IVC and PV are washed with

heparinized saline to clear any clots that may have
formed.
• Portal vein and IVC are approximated by stay
sutures placed into the upper and lower angles of
the anastomosis using 4-0 / 5-0 vascular suture and
with knots outside (See Fig. 9.2)
• One corner suture is brought to the inside through
the inferior vena cava. End to side anastomosis is
done beginning with posterior row using an over
and over suture technique.
• Sutures should be lubricated well, eased gently
through the vessel wall.
• After completion of posterior layer, needle is
brought through anterior wall and angle is tied.
• Anterior layer is then sutured by over and over
suturing, PV is gently eased down to IVC to avoid
tearing.
• At the end of anastomosis PV should gently curve
to join the IVC.
• Anterior layer and corners are inspected for any
tears or holes after which clamp is released and
gentle pressure applied with small gauze/swab.
• If there are holes which bleed in spite of gentle
pressure, they are closed with 4-0/5-0 interrupted
sutures.
• Pressure within the splanchnic circulation is
measured again, and the fall should be to normal
or at least 20% above the normal pressure; or
there should be a gradient of not more than 5 cm

of saline, which indicates a functioning shunt.
Intraoperative Problems
• Anatomical pitfalls
• While dissecting the portal vein circumferen-
tially, veins arising from its anteromedial aspect
such as pyloric, accessory pancreatic and
coronary veins should be looked for.
• Superior pancreaticoduodenal vein should be
looked for and ligated as the portal vein
disappears behind the neck of pancreas.
• Aberrant right hepatic artery from SMA (15%
to 20%) runs posterolateral to CBD on top of
or occasionally behind the portal vein. This
should be carefully preserved. When the portal
vein is pulled posteriorly to appose the IVC, the
aberrant right hepatic artery may kink or
partially obstruct the portal vein causing shunt
occlusion.
• At the end of surgery, no change in pressures
indicates a functionally ineffective shunt.
• Angulation at the site of anastomosis should be
looked for
• Further mobilization of the PV is attempted.
• If not successful shunt is taken down and
refashioned.
• Kinking/angulation of the PV near its origin at
the head of pancreas
• Further mobilization of PV/SMV/SV may

correct the problem.
• Effective anastomosis is evidenced by
• Little or no bleeding from the anastomosis
• Immediate stoppage of oozing from adjacent
venous collaterals
• Palpable thrill at the site of shunt and over IVC
Closure
• Preferred without drains to avoid loss of ascetic
fluid
• Usually closed with single layer no.1 nonabsor-
bable suture
• Skin is closed with clips or sutured with no. 3-0
nylon.
Postoperative Care
• Vital signs are monitored carefully for initial 48
hours to 72 hours.
• Fluid intake – 10% dextrose to have adequate
supply to liver
• Broad spectrum antibiotics started preoperatively
and continued for 36 hours to 48 hours
postoperatively.
• Nasogastric tube can be removed on 2nd or 3rd
postoperative day.
• Light diet low in protein and sodium is started on
4th or 5th postoperative day.
• Liver function tests are monitored.
• Daily weight is recorded to detect onset of ascites

or edema. If portal vein happens to be the major
outflow pathway for the liver because of reversal
of flow, intractable ascites may develop after an
end-to-side portacaval shunt because of increased
pressure on the hepatic side than on the splanchnic
side. The situation would be worse if the umbilical
vein in the falciform ligament is also ligated.
• Usually patients can be discharged by 10th or 12th
day.
• After emergency portacaval shunt there may be
more complications in the form of
• Pulmonary edema
• Hepatic failure and
• Renal failure
TECHNICAL FEATURES IMPORTANT IN

PERFORMING PORTACAVAL SHUNT
• Position of patient on table is crucial and is the dif-
ference between an easy and a difficult operation.
• Long right subcostal incision has fewer
postoperative complications than a thoraco-
abdominal incision
• Use of good electrocautery or harmonic scalpel
throughout operation reduces the operating time
as well as blood loss.
• Bleeding from collaterals is managed best by
pressure with packs. Most of the bleeding stops
once shunt is complete and portal pressure
reduces. Aim is to decompress the portal system

as soon as possible.
• IVC is mobilized circumferentially from the
entrance of renal vein to the liver.
• Portal vein is mobilized for a long segment, by
dividing the fibro fatty tissue between the portal
vein and pancreas, may require division of a part
of pancreas, to bring the portal vein in apposition
to IVC.
• Caudate lobe resection is not necessary and causes
more blood loss.
• Pressures in the IVC and portal vein are to be
measured following anastomosis. Pressure gradient
of more than five cm of saline is not acceptable
and may require revision of shunt.
SIDE-TO-SIDE PORTACAVAL SHUNT (SSPCS)

• The side-to-side portacaval shunt was initially
proposed to offset the total diversion of portal
blood flow and the consequent increased chances
of encephalopathy. However, it is now shown that
side-to-side shunt of sufficient caliber does not
achieve this purpose and functions as a total shunt
in course of time.
• However, it converts the portal vein in to an
outflow tract thus relieving the hepatic sinusoidal
hypertension and in turn relieving the intractable
ascites.
Indications
• Variceal bleeding in patients with ascites that has
been intractable to medical management.
• Budd-Chiari syndrome in its early stages before
cirrhosis has developed – particularly in patients
with obstruction of the hepatic veins alone.
Position
• It is similar to the position in end-to-side
portacaval shunt.
Incision
• Similar to the one described for end-to-side
portacaval shunt.
Steps of Operation
• Steps of hepatic flexure mobilization, duodenal
Kocherization and IVC mobilization are same as
in previous procedure. But more extensive
dissection of the portal vein and inferior vena cava
is necessary.
• IVC is isolated circumferentially and taped. For its
isolation a few tributaries like the right adrenal
vein, one or two pairs of lumbar veins which enter
posteriorly, and caudal pair of hepatic veins which
enter directly on the anterior surface of IVC are
ligated and divided.
• Above step is crucial to approximate the IVC and

PV for SSPCS.
• Portal vein is located on the posterolateral aspect
of portal triad.
• Fibrofatty tissue on this aspect is dissected using
blunt and sharp dissection, as there are no venous
tributaries.
• Hepatic artery and common bile duct are retracted
medially once portal vein is exposed.
• Portal vein is mobilized circumferentially at mid
portion and isolated above up to bifurcation.
• Portal vein is pulled out of pancreas and is cleared
off the fibrofatty tissue which binds it to the
pancreas; may require division of a part of pancreas
• Failure to achieve this mobilization is a major
reason for difficulty in doing this shunt.
• Measurement of pressures within the IVC and
portal vein is important before and after the shunt.
• Satinsky clamp is placed obliquely across a five cm
segment of anteromedial wall of IVC, so that it is
parallel to the direction of PV.
• Portal vein is isolated for a segment of five cm
between two-angled vascular clamps.
• 2 to 2.5 cm elliptical buttons of IVC and PV are excised
with Pott’s scissors. It is important to fish-mouth the
vessels in stead of making a simple incision.
• Retraction suture 5-0 prolene is placed on the
lateral wall of IVC and attached to a hemostat to
keep the lumen open.
Fig. 9.3: Side-to-side portacaval anastomosis in progress,

positioning of vascular clamps
• Portal vein clamps are released momentarily to

flush out any clots.
• Lumens of IVC and PV are flushed with
heparinized saline.
• Anastomosis is started with posterior row of
continuous over and over suture using 5-0 vascular
suture (prolene).
• At each corner, the suture is tied after the
posterior continuous layer is over.
• Anterior row is then completed with over and
over suture using same 5-0 vascular stitch, starting
at either corner.
• Superior suture is left loose after three or four
throws, to visualize the interior and to avoid
inclusion of posterior layer inadvertently till
the centre is reached.
• Inferior suture is similarly started till it reaches
the superior suture after which they both are
tied to each other. Prior to this, portal clamps

are released again momentarily to release any
clots and the anastomosis is irrigated with
heparinized saline.
• Single interrupted stitch is taken on either end of
the anastomosis just beyond each end, to take the
tension off the anastomosis.
• Vascular clamps are released starting from the IVC
clamp first, followed by the hepatic end of portal
vein and lastly the clamp on intestinal end of PV.
• Any bleed or ooze is taken care of by pressure or
at the most interrupted stitch using 5-0 vascular
stitch.
• Pressure in the IVC and PV must be measured at
the end of anastomosis, which should be similar
• Pressure gradient of more than five cm saline
between the vessels indicates some obstruction in
the shunt.
• In such a situation, the anastomosis is opened to
release any clots that may have formed. A revision
of anastomosis is some times required to ensure
long-term patency.
Postoperative Care
• Similar to care after ESPCS
• In Budd-Chiari syndrome, anticoagulation in the
form of heparin (5000 iu) is administered intra-
venously at the time of anastomosis and continued
postoperatively in order to prevent shunt thrombo-
sis, which is the commonest complication (25%).
• Heparin is converted to oral anticoagulants later

which are titrated to maintain an INR between
2 and 2.5. This is continued lifelong.
INTERPOSITION H GRAFT PORTACAVAL

SHUNT (HGPCS)
• Side-to-side portacaval shunt is not only difficult
to make but is a total shunt and can cause post-
operative problems of encephalopathy.
• These problems are circumvented with the use of
small diameter interposition H graft portacaval
shunt.
• The procedure has undergone numerous modifi-
cations and the size of graft has gradually reduced
from 10 mm to 26 mm initially to the present
diameter of 8 mm.
• Dacron grafts used initially are now replaced by
Polytetrafluoroethylene (PTFE) grafts which have
less chances of thrombosis.
• Advantage of small diameter interposition shunt
is that, it decompresses the portal system
adequately to avoid variceal rebleed, at the same
time, it maintains a prograde flow to the liver, thus
reducing the problem of encephalopathy.
• It is a treatment option, as stated, for patients with
variceal bleed who are not candidates for liver
transplant.
Position of Patient, Incision and Exposure of

IVC and Portal Vein
• As in the previous section.
Preparation of Graft
• Eight mm ribbed (externally reinforced),
Polytetrafluoroethylene (PTFE) graft is used for
the shunt because supported grafts develop a
gentle bow without an acute kink after releasing
traction on the liver whereas unsupported PTFE
grafts tend to kink or are compressed by adjacent
viscera.
• Long bevels are fashioned at both ends of the graft
at almost right angles to each other as the portal vein
is not parallel to IVC but is at 60 degrees to IVC.
• Graft length usually required is between three and
five cm.
• Graft after being beveled in above fashion is
placed in a syringe containing heparinized saline.
Occluding the tip with finger, the plunger is
pushed in and out several times to dislodge the
air from the graft. On removing the suction on
plunger, once air is totally removed, graft no
longer floats in saline.
• Air in the graft is thus replaced by heparinized
saline.
• It helps in easy identification by Doppler’s
ultrasound in postoperative period.
IVC Anastomosis
• Graft is placed on the IVC and the need for
trimming of caudate lobe is now made.
• If required, it should be done at this step, using
cautery and placing traction on the tip of caudate
to be excised.
• Side biting Satinsky clamp is placed on the IVC and
is fully closed to avoid slipping of the IVC out of
clamp.
• A small window is cut on the IVC, which should
be ventral to dorsal instead of cephalad to caudad.
This opens up the anastomosis for a better outflow
from the graft.
• Graft is placed on the IVC in such a manner that
it leans cephalad.
• The pre-cut bevel causes the graft to angle
approximately 30 degrees cephalad from the
anterior surface of the vena cava.
• Suturing is begun with horizontal mattress suture
at the cephalad aspect of anastomosis at the heel
of graft.
• Running suture is then taken in a fashion that
sewing along the vein is from inside out and at
the graft is from outside in.
• Posterior wall of anastomosis is constructed first,
and first few sutures are parachuted down which
otherwise can be quite difficult.
• Once the toe of graft is reached from posterior
row, other limb of 5-0 prolene stitch is returned
Fig. 9.4: Interposition graft in situ
to and anterior wall of anastomosis is then

completed (Fig. 9.4).
• Tension on the suture is kept on throughout, to
avoid loose anastomosis and the need to tighten
it at the end of anastomosis.
• Suture is reversed before tying, and at the end any
gaps or defects in the anastomosis are looked for
by placing a right-angled clamp across the graft
and taking the Satinsky clamp off the IVC.
• Satinsky clamp is then replaced on IVC and right
angled clamp is removed from the graft.
• Graft is then irrigated thoroughly with heparinized
saline, using 18G angiocatheter and 30 ml syringe.
Portal Vein Anastomosis

• Portal vein is then clamped with a small Satinsky
clamp.
• Posterolateral aspect of PV is opened with no.11
knife. Once entered, the hole in portal vein is
opened up using Pott’s scissors. Cutting a window
is not mandatory.
• A 5-0 prolene suture is placed on ventral wall of
PV to retract and keep the hole in PV open.
• Posterior wall of the hole in PV is then sutured to
the graft using double armed 5-0 prolene.
• The portal anastomosis is facilitated by pre-placing
the entire posterior suture line before coapting the
graft to the PV.
• Initial stitch is a horizontal mattress suture which
is started in the midportion of anastomosis and
proceeded in cephalad portion of anastomosis
• All the suturing is from inside out on PV side and
outside in on the graft side.
• Once the end is reached on cephalad aspect, suture
is held in rubber shod, and suturing is started
with the other end of prolene stitch, keeping the
stitch taut throughout.
• Anastomosis then proceeds from both the ends
towards midportion of anterior wall of
anastomosis.
• Vascular clamp on portal vein is momentarily
released to give way to clots or debris within the
portal vein.
• Before the portal anastomosis is completed, the

graft is flushed with heparinized saline to remove
thrombi, fibrin, and other tissue debris.
• Heparinized saline is again used for irrigation of
graft before tying the knot which is done after
reversing one of the ends of suture to tie across
the anastomosis.
• Clamp on the IVC is released first followed by that
on the PV.
• Thrill should be palpable on the IVC cephalad to
anastomosis for the shunt to be patent.
• In case of doubt, a small opening (one to two
mm) is made in the anterior midportion of the
graft.
• A 1 ml Fogarty balloon catheter is passed
through both anastomoses and withdrawn with
the balloon inflated.
• This maneuver removes small thrombi from the
portal vein (accumulated during clamping) and
ensures that the anastomoses are free of
technical errors.
• Following construction of the shunt, portal
collateral veins are interrupted.
• The umbilical vein is divided at the liver edge.
• The gastroepiploic veins are interrupted in
continuity with surgical clips.
• The large periesophageal veins on the medial
side of the esophagus are also suture-ligated.
• The coronary vein is suture-ligated in the lesser
sac as it enters the gastrohepatic ligament.
• The inferior mesenteric vein is interrupted at

the ligament of Trietz.
• The aim of collateral ligation is to direct more
portal flow towards the liver and shunt. This
provides additional protection against continued
hemorrhage in actively bleeding patients.
• However opinion regarding interruption of
collaterals is divided with original opinion of
Sarfey’s favoring disconnection while further studies
by Rosemurgy disagreeing with the concept.
Pressure Measurements before after Shunting

• Both IVC and PV pressures are measured before
applying clamps.
• IVC and portal pressure gradient is generally
20 mmHg, before shunting with 30 mmHg in PV
and 10 mmHg in IVC.
• After shunting the gradient should fall consi-
derably, and be less than 10 mmHg, with marked
reduction in PV pressures to within 7-10 mmHg
and slight increase in IVC pressures.
Closure
• Operative field is irrigated with saline
• Wound is closed with 1-0 prolene suture in
anatomical layers.
• Wound should not be closed too tightly to avoid
necrosis, at the same time fascia is closed in two
layers with well-placed sutures to avoid ascitic leak

in postoperative period.
• Subcutaneous tissue is also irrigated with saline,
skin is closed with nylon sutures.
• Suture removal is delayed to avoid wound dehis-
cence and time is allowed for wound contraction
Postoperative Care
Postoperative care is given as described for other
portacaval shunts. Although Sarfeh in his original
description suggests a routine angiogram within one
week of surgery on all patients with advances in real
time duplex ultrasonography, invasive angiogram
may not always be indicated.
• Early shunt thrombosis is managed by inflating a
balloon catheter in the shunt.
• Once some flow is established, an angiography
catheter is left with the tip in the portal vein
adjacent to the anastomosis. Streptokinase is
infused at 5000 U/h for 24 hours, and angiography
is repeated.
RESULTS OF PORTACAVAL SHUNTS

The largest body of data on portacaval shunt is from
Orloff and associates whose results have been
unparalleled. In 400 consecutive unselected patients
who underwent emergency portacaval shunts – mostly
side-to-side – they reported a 10-year survival of 78%
in child’s A and 76% in child’s B classes and a long

term shunt patency rate of 100%. In an elective setting,
the same group has reported a consecutive 1000
patients with biopsy-proven cirrhosis — 89% of whom
were in child’s classes B and C - had an elective
portacaval shunt and were followed for more than
10 years with a follow up rate of 99.6%. Long-term
patency was demonstrated in 99.7% of patients and
survival rates were 95% at one year, 71% at 5 years
and 65% at 10 years and 61% at 15 years.
Unfortunately this experience stands in stark contrast
to those of most other groups who uniformly
reported perioperative mortalities of about 40% and
5-year survival rates of about 30%.
Partial portal systemic shunts were popularized in
the 1980s and 1990s by reducing the diameter of side-
to-side shunts to 8 mm. Sarfeh and colleagues showed
that this was the critical diameter at which portal
pressure was reduced to 10 mm Hg or less and some
portal flow was maintained to the cirrhotic liver in
80% of patients.
The superiority of operatively achieved (HGPCS)
versus radiologically achieved (TIPS) partial portal
decompression has been argued. While it is generally
accepted that TIPS is the preferred modality of
treatment in patients waiting for liver transplantation,
Rosemurgy et al prospectively studied the role of
TIPS versus HGPCS in the treatment of variceal bleed
and the observations are summarized as follow:
TIPS HGPCS
Reduction in Pressure 32±7.5 to 30±4.6 to

25 ± 7.5 mm Hg 19±5.3
Early graft occlusion(<30 days) 17% 9%
Late occlusion 14% 3%
Major rebleed 11% Nil
Encephalopathy(30 days) 29% 26%
Ascites 92% 68%
Death 34% 20%
Shunt failure 57% 26%
These authors have concluded that although both

TIPS and HGPCS reduce portal pressure, placement
of TIPS resulted in more deaths, more rebleeding and
more than twice treatment failures. Mortality and
failure rates promote the application of HGPCS over
TIPS and they recommend that HGPCS should be
preferentially applied for acceptable patients with
cirrhosis and variceal bleeding who had failed or are
not amenable to endoscopic therapy without access
to convenient capable postshunt care or without
definitive plans for imminent transplantation.
There have been very few published reports of
portacaval shunt from India. They include six side-
to-side portacaval shunts for hepatic venous outflow
obstruction from AIIMS, 13 portacaval shunts(one end
to side and 12 interposition) as salvage surgery from
SGPGI, Lucknow and three portacaval shunts for
Budd-Chiari syndrome from KEM Hospital, Bombay.
In the department of surgical gastroenterology,
NIMS, Hyderabad too portacaval shunt has not been
a popular operation. Of the 141 operations done for

portal hypertension in 20 years, only 4 portacaval
shunts (two end-to-side and two H grafts) were done.
Both the patients in whom end-to-side portacaval
shunts were done, in the very early phase of the
experience, had postoperative deaths. With the good
results of splenorenal shunts and esophagogastric
devascularization procedures, these two have become
the standard operations leaving the portacaval shunt
(side-to-side) the procedure of choice only in hepatic
venous outflow obstruction or when intractable
ascites accompanies a major bleed in child’s A
cirrhotics.
BIBLIOGRAPHY
1. Kohli V, Pande GK, Dev V, Reddy KS, Kaul U, Nundy S.
Management of hepatic venous outflow obstruction. Trop
Gastroent 1998; 19: 82-95.
2. Orloff MJ, Orloff MS, Orloff SL, et al. Three decades of
experience with emergency portacaval shunt for acutely
bleeding esophageal varices in 400 unselected patients with
cirrhosis of the liver. Jour Am Coll Surg 1995; 180: 257–72.
3. Orloff MJ. Prophylactic portasystemic shunt in non-cirrhotic
portal fibrosis: Is it worthwhile? Nobody knows (Editorial).
Indian Jour Gastroent. 2005; 24: 233-4
4. Rosemurgy AS, Bloomston M, Clark WC, et al. H-graft
portacaval shunts vs. TIPS: Ten year follow-up of a
randomized trial with comparison to predicted survivals. Ann
Surg 2005; 241: 238–246.
5. Shah SR, Narayanan TS, Nagral SS, Mathur SK. Surgical
management of the Budd-Chiari’s syndrome: Early experience.
Indian Jour Gastroent 1999; 18: 57-9.
6. Sharma A, Vijayaraghavan P, Lal R, Behari A, Kumar A, Sikora
SS, Saxena R, Kapoor VK. Salvage surgery in variceal bleeding due
to portal hypertension. Indian Jour Gastroent 2007; 26: 14-7.
CHAPTER 10
Portal Vein
Resections and
Injuries
Rajneesh Kumar Singh

Vinay Kapoor
INTRODUCTION
Portal vein (PV) carries about 80% of the blood supply
of the liver, which comes mainly from the superior
mesenteric vein (SMV) and the splenic vein. Majority
of reports on PV surgery deal with its resection during
elective surgery. There is very little information
available on traumatic injuries to the PV/SMV, and
reports on iatrogenic injuries to PV/SMV are very
few. The present chapter reviews the current status
of PV/SMV resections and management of injuries.
SECTION 1
Portal Vein/Superior Mesenteric Vein Resection
during Pancreaticoduodenectomy
• Traditionally, peri-ampullary and pancreatic malig-
nancies involving major veins have been deemed
unresectable. Maverick surgeons of the past had
occasionally tried resecting such tumors, often with
disastrous results. Fortner set the ball rolling more
than three decades back when he reported the
feasibility of major vascular resection for locally
advanced pancreatic tumors. Since then resection
of major veins (and occasionally arteries) during
pancreaticoduodenectomy has been reported in
increasingly large numbers from high volume
centers.
The nihilistic view still holds that tumors
adherent to or involving major veins are far too
Portal Vein Resections and Injuries 143
advanced for surgical salvage. On the other hand,

the ‘radical’ surgeons would like to resect any and
every locally advanced tumor even if it may be
invading major veins/arteries. The logic behind
such an approach is the data suggesting that
tumors involving major veins are no more
aggressive than others. However many groups
have reported that these patients (after major
venous resection) do have a poor prognosis and
long-term survival is limited. Such tumors also
have a higher incidence of margin positivity, lymph
node metastasis and worsening grade.
• Factors to be considered before deciding for PV/
SMV resection during PD include:
i. Prediction of an R0 resection (considering the
stage of the tumor)
ii. Extent of PV/SMV involvement
iii. Suspected pathology of the tumor (pancreatic
ductal adenocarcinoma or another tumor with a
better prognosis)
iv. Experience of the surgical unit in carrying out
such major resections with low morbidity and
mortality.
Preoperative Workup
• Accurate preoperative staging and assessment of
lymph nodes and distant metastasis is of utmost
importance.
• Imaging
i. A contrast enhanced multi-slice CT scan with
reconstruction is the most helpful investigation
to assess resectability of pancreatic and
periampullary carcinoma. The need for venous
resection could be predicted by CT scan in 84%
of the patients.
ii. US Doppler assessment provides further infor-
mation about the involvement of the major veins.
iii. Endoscopic Ultrasound (EUS) has also shown a
great promise in diagnosing venous invasion.
A meta-analysis has shown that the specificity of
EUS was high (90%) but the sensitivity was not
so high (73%). At present it is therefore recom-
mended to use it only for further investigating
cases which are suspected to have venous
involvement on CT scan.
iv. Angiography is not routinely carried out at most
centers for assessing PV/ SMV, because it is an
invasive investigation and may miss findings of
minimal vein involvement. If needed, MR angio-
graphy can substitute for invasive angiography
to assess the vessels, but is not routinely carried
out.
v. A tumor with a simple loss of fat plane or
abutment to the PV/ SMV is not considered to
be a criteria of unresectability.
• Assessment for anesthesia risk.
• Hematological investigations
• Biochemistry
• Coagulation parameters
• Arrangements need to be made for availability
of adequate amount blood and blood products.
Position
Supine with head end of table raised 30°.
Incision
A roof-top incision or long midline incision.
Steps of Operation
• Prevention of hypothermia, hypotension and
acidosis is of vital importance. Wide exposure is
ensured by mobilizing the mesenteric base.
• PV/ SMV resection is the last step in order to
minimize the PV/ SMV occlusion time. As soon as
the veins are divided the specimen is removed and
venous reconstruction is proceeded immediately
thereafter.
• After extensive Kocherization of the pancreatic
head and duodenum, these structures are retracted
ventrally and to the left.
• The PV/ SMV complex is retracted to the left and
the uncinate process (along with the lymphatic
tissue) is carefully separated from the superior
mesenteric artery while staying close to the right
border of the artery.
• After posterior tissues are free the surgery is

proceeded as routine.
• For PV/ SMV division ‘Superior mesenteric artery
first’ approach is followed. The SMA is dissected
first and looped.
• The PV/SMV is approached from behind after
separating the SMA from the pancreatic head.
• An alternative anterior approach involves early
division of pancreatic neck and the splenic vein.
This allows the pancreatic head/ duodenum/
adherent PV/SMV to be retracted laterally. Then
the separation of the tissues for the right border
of SMA can proceed from anteriorly.
• In case of an intraoperative surprise finding of
tumor adherence to the PV/ SMV, the decision to
proceed further needs to be made before taking
any irreversible step. If the tumor is discovered
to be adherent to the PV/ SMV after division of
the neck of the pancreas, resection of a part of the
PV/ SMV becomes mandatory.
• Occlusion of the PV/SMV blocks the venous
outflow of the bowel draining into the portal
system (small intestine and most of the large
intestine). This leads to bowel edema and hepatic
ischemia, which limit the duration for which the
PV/SMV can be clamped. In order to reduce the
bowel edema and prolong the occlusion time
needed for the reconstruction– temporary
clamping of the superior mesenteric artery, venous
bypass of the portal venous blood and careful fluid

management is required to avoid over-infusion of
crystalloids. Side clamping of the PV/SMV for
partial excision of the vein wall if feasible may
avoid complete occlusion of the venous outflow.
• The duration for which the PV/ SMV could be
safely occluded, in the absence of venous bypass
is approximately of 20-30 minutes.
• On the other hand if the occlusion time is expected
to exceed 30 minutes it is recommended that simul-
taneous occlusion of SMA and PV/SMV should be
done to prevent excessive bowel congestion.
• If the occlusion time more than 60 minutes then
a veno-venous bypass between SMV and a
systemic vein is required to be done.
• The veno-venous bypass is a ‘passive’ bypass using
a patented anti-thrombogenic catheter (Anthron
tube – manufactured by Toray Industries Inc,
Tokyo, Japan).
• The bypass is done between the SMV and femoral
vein and the SMV and hepatic portion of the PV.
• Another way to bypass is to use a centrifugal
pump-assisted venous bypass. A pump assisted
bypass is able to maintain a larger flow as
compared to a ‘passive’ bypass but may lead to
problems of hemolysis or thrombocytopenia. A
Bio-pump, Medtronic Bio-Medicus, Eden Prairie,
MN, USA is used for bypass between the SMV and
the umbilical vein.
• A direct catheter shunts between the two divided

ends of the PV/SMV to maintain flow during
reconstruction has also been described.
• The use of systemic heparin during PV/SMV
occlusion is an important consideration most of the
workers performing PV/SMV resections do not
use heparin or any other form of therapeutic
anticoagulation; others however, use it routinely.
• Use of heparin is however, important when using
bypass procedures to prevent the risk of coagu-
lation in the tubings.
• A low dose aspirin (80 mg/d) within 24 hours after
surgery and continuing indefinitely has also been
recommended.
Wedge Resection
In cases of partial involvement of the PV/SMV a small
wedge of the lateral wall of the vein can be excised
and reconstruction done. This is achieved by using a
side biting vascular clamp on the vein while
maintaining partial flow. Wedge resections is usually
limited to 1-2 cm.
• Large wedge resections of the vein requires
complete occlusion and is difficult to reconstruct.
• The reconstruction of the resulting defect is done
by primary repair (lateral venorrhaphy), using an
autologous vein patch or a prosthetic vein patch.
Conventionally, lateral venorrhaphy is limited to
only small defects so as to avoid excessive

narrowing of the vein.
• Segmental resections of PV/SMV have also been
practiced by same surgeons. The main issue which
requires to be addressed in this kind of procedure
is preservation of the splenic vein/ PV confluence
with subsequent, reconstruction of the PV/SMV
and the splenic vein.
• Preservation of splenic vein/PV confluence
It is desirable to preserve the PV-splenic vein
junction (either whole or part) during segmental
venous resections. The junction is best divided
obliquely so as to preserve even a strip of vein
wall. It may then be possible to obliquely position
the vascular clamp, to allow the splenic vein to
maintain some flow into the portal vein during
venous occlusion. The strip of vein wall also serves
to orient the anastomosis and prevent rotation.
Preserving the PV-splenic vein junction may
however, limit the mobilization of the PV. Primary
anastomosis is only possible if segmental resection
is restricted to 2 cm.
• Reconstruction after segmental resection of the
PV/SMV is done in one of the three ways, i.e.
primary end-to-end anastomosis, an autologous
vein graft or a prosthetic graft.
• The primary end-to-end anastomosis is done if the
two vein ends can be brought together without
tension. Extensive mobilization of the mesentery
and liver could be done to allow major segmental

defects to be bridged without any graft. The
length of the segmental defect that has been
bridged with an end-to-end anastomosis has
varied from 2 cm to 10 cm. Usually preservation
of PV-splenic vein junction allows end-to-end
anastomosis for only defects upto two cm.
• An autologous vein graft used for bridging the
defect is taken from the internal jugular vein, left
renal vein, superficial femoral vein, saphenous
vein, external iliac vein. Alternatively previously
preserved vein grafts (from cadaveric donors)
could be used. The choice is often a matter of
surgeons’ preference. Internal jugular vein graft has
been a conventional favorite because of the long
length, ease of harvest and good size match. Left
renal vein graft has the advantages of being
accessible through the same incision. Superficial
femoral vein graft is generally unfamiliar to the
abdominal surgeons and may occasionally lead to
limb swelling for a short period. Saphenous vein
and external iliac veins can also be used.
Autologous vein grafts are preferred over
prosthetic grafts as the risk of graft thrombosis is
lower. Prosthetic grafts have the advantage of
being readily available.
• Reconstruction is done with fine sutures
(6-0 prolene) taking care to avoid problems of
tension, kink, torsion and redundancy. Extensive
mobilization and retraction they lead to a

clockwise twist in the mesentery and therefore
must be taken into account during reconstruction.
For proper orientation of the ends, these are
marked before resection either with fine sutures
or inking of the anterior wall.
• Splenic vein reconstruction is optional. Many
surgeons do not reconstruct the splenic vein after
PV/SMV resection and have not report any
problem. However, few centers have encountered
left sided portal hypertension and bleeding varices
after splenic vein ligation. Splenic vein also plays
a major role in maintaining gastric blood flow
after pylorus preserving pancreaticoduodenectomy
whenever possible therefore, splenic vein should
be reattached after reconstruction of the PV/SMV
segment.
• Very few long-term patency studies are available
after PV/SMV resection and reconstruction.
Thrombosis rates have been found to be higher in
those with PTFE grafts. Prophylactic anticoagula-
tion does not seem to make any difference to the
rate of thrombosis.
Results
• Morbidity and mortality
The initial morbidity and mortality of PV/ SMV
resection was high but recent results have shown that
this major procedure can be carried out with the same
morbidity and mortality as a classical PD without

venous resection, albeit with a longer operation time
and more blood loss. A recent review reported a
pooled 6% mortality and a median 42% morbidity for
PD with PV/ SMV resection.
• Prognosis
Many other centers have also reported equally good
survival for patients undergoing vascular resection.
Contrary to this others have reported a dismal
prognosis in these patients, due to high incidence of
margin positivity and lymph node involvement. The
margin positivity has been reported to vary from 13%
to 59%. Ishikawa et al have classified vascular
involvement into 5 types and concluded that PV/ SMV
resection is only justified in patients with less than
semi-circular circumference of vein involvement and
<1.2 cm length involvement of the vein. However, the
incidence of vein wall invasion on pathology has been
found to be highly variable (3% to 82%) in patients
undergoing PD and PV/ SMV resection. The data
from the patients with true pathologic vein wall tumor
invasion seems to suggest that they fare much worse
than those with just inflammatory adhesions. On a
multivariate analysis a tumor free resection margin
was found to be the most important prognostic factor.
SECTION – 2
Portal Vein/Superior Mesenteric Vein Injury
Most of the already sparse literature on PV/SMV
injuries relates to traumatic injuries secondary to
abdominal gun-shot or stab injuries. Iatrogenic injuries
to PV/SMV are grossly under-reported and there are
only few such published reports. Hence the
management of iatrogenic injuries to PV/SMV is
largely an extrapolation of the experiences and results
of traumatic PV/SMV injuries and elective resection
of PV/SMV during pancreaticoduodenectomy.
Traumatic Injuries
The reported fatality rates of traumatic injuries of
PV/SMV are very high (39 to 71%). Multiple injuries
including major vascular injuries like IVC and aorta
are invariably present in upto 70-90% of the patients.
• On site initial assessment and resuscitation is important.
Once the patient reaches the hospital, beside
resuscitation and fluid replacement the cause of the
shock is determined as soon as possible, and once
intra-abdominal hemorrhage is suspected to be the
cause, preparations are made for an expedient
laparotomy.
• Exposure of the PV requires extended Kocheri-
zation of the duodenum and mobilization of the
hepatic flexure of colon. An innocuous looking
hematoma in the hepatoduodenal ligament may
mask a serve PV/SMV injury. One must ensure the

availability of instruments like vascular clamps,
etc, equipment and manpower before proceeding
further. There may well be more than one vascular
injury. Bleeding from PV/SMV injuries can often
be stopped temporarily by compression. This also
allows immediate attention to be directed to
associate caval or arterial injuries.
• Bleeding from PV/SMV is temporarily arrested
using vascular clamps, are applied to the hepato-
duodenal ligament and SMV below the pancreas.
This decreases but does not stop bleeding. The
primary venous injury is then identified and
vascular clamps applied on the two sides of the
rent.
• Access to the retropancreatic PV/SMV injuries is
often more difficult. These are often associated
with pancreatic injuries. Extensive Kocherization
is needed along with good understanding of the
anatomy of the region. Deliberate division of the
neck of pancreas has been advocated to provide
access to the PV/SMV.
• The PV/SMV injuries are managed either by-
lateral repair, end-to-end repair or by using an
interposition graft. In an unstable patient in shock,
simple ligation has also been done. PV/SMV have
good channels of collateral venous drainage
(including inferior mesenteric vein, coronary vein,
etc). The collateral venous drainage works best
when the ligation is close to the confluence of the

PV/SMV/Splenic veins and is the worst for high
ligation of the PV close to the porta hepatis.
Reconstruction of PV is however, mandatory if
there is concomitant injury to hepatic artery or
extensive damage to potential collaterals.
• Prolonged clamping and ligation have the same
effects to those of acute PV/SMV thrombosis.
There is pooling of blood in the splanchnic
circulation and massive bowel edema. The
splanchnic vascular trapping results into low the
central venous pressures and large amount of
intravenous fluid replacement (partly colloids) is
required. Massive bowel edema occurs over the
course of next few days, it is therefore advisable
to close skin only or use a laparotomy after the
first surgery. A relook surgery may alternatively
be done after 24-48 hours to inspect bowel for
viability.
Iatrogenic Injuries
• PV/SMV injuries can occur during upper
abdominal operations on the stomach, duodenum,
pancreas, gallbladder, etc. Most are not reported
and thus published reports are few. The leading
causes for the occurrence of such injuries are
oncologic resections, difficult anatomic exposures,
previous operations, recurrent tumors and patients
who received earlier radiation therapy.
• The principles of management remain the same as

that for trauma. The major difference being that
these usually happen in elective surgery and are
thus more controlled circumstances. However the
anatomic exposure is more difficult, usually
because of the underlying problem which lead to
the injury in the first place.
• Iatrogenic injuries are usually more isolated than
multiple, as opposed to penetrating trauma. The
options for repair remain the same as for trauma
– lateral repair, end-to-end repair, graft and
ligation. Ligation is however less commonly
accepted in these circumstances.
BIBLIOGRAPHY
1. Bachellier P, Nakano H, Oussoultzoglou PD, Weber JC,
Boudjema K, Wolf PD, et al. Is pancreaticoduodenectomy with
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Jour Surg 2001; 182: 120-9.
2. Bold RJ, Charnsangavej C, Cleary KR, Jennings M, Madray A,
Leach SD, et al. Major vascular resection as part of
pancreaticoduodenectomy for cancer: radiologic, intraoperative,
and pathologic analysis. Jour Gastrointest Surg 1999; 3:
233-3.
3. Buckman RF, Pathak AS, Badellino MM, Bradley KM. Portal
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4. Busuttil RW, Kitahama A, Cerise E, McFadden M, Lo R,
Longmire WP Jr. Management of blunt and penetrating injuries
to the porta hepatis. Ann. Surg. 1980; 191: 641-8.
5. Capussotti L, Massucco P, Ribero D, Viganò L, Muratore A,
Calgaro M. Extended lymphadenectomy and vein resection for
pancreatic head cancer: outcomes and implications for therapy.
Arch Surg. 2003; 138: 1316-22.
6. Carrère N, Sauvanet A, Goere D, Kianmanesh R, Vullierme MP,
Couvelard A et al. Pancreaticoduo-denectomy with mesenteri-
coportal vein resection for adenocarcinoma of the pancreatic
head. World Jour Surg 2006; 30: 1526-35.
7. Clavien PA, Rüdiger HA. A simple technique of portal vein
resection and reconstruction during pancreaticoduodenectomy.
Jour. Am. Coll. Surg. 1999; 189: 629-34.
8. Dardik H, Shander A, Dardik S, Silvestri F, Ciervo A, Beotti
PN. Portal mesenteric shunting for reconstruction of the visceral
venous system. Jour Am Coll Surg 2000; 191: 469-73.
9. Fleming JB, Barnett CC, Clagett GP. Superficial femoral vein
as a conduit for portal vein reconstruction during
pancreaticoduodenectomy. Arch Surg 2005; 140: 698-701.
10. Fortner JG. Regional resection and pancreatic carcinoma.
Surgery. 1973; 73: 799-800.
11. Howard TJ, Villanustre N, Moore SA, DeWitt J, LeBlanc J,
Maglinte D, McHenry L. Efficacy of venous reconstruction in
patients with adenocarcinoma of the pancreatic head. Jour
Gastrointest Surg 2003; 7: 1089-95.
12. Huerta S, Li Z, Livingston EH. Outcome of portal injuries
following bariatric operations. Obes Surg 2006; 16: 105-9.
13. Jurkovich GJ, Hoydt DB, Moore FA, et al. Portal triad injuries.
Jour Trauma 1995; 39: 426–33.
14. Koniaris LG, Schoeniger LO, Kovach S, Sitzmann JV. The quick,
no-twist, no-kink portal confluence reconstruction. Jour Am Coll
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15. Lygidakis NJ, Singh G, Bardaxoglou E, Dedemadi G, Sgourakis
G, Nestoridis J. Mono-bloc total spleno-pancreatico-
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16. Nakagohri T, Kinoshita T, Konishi M, Inoue K, Takahashi S.
Survival benefits of portal vein resection for pancreatic cancer.
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Sullivan T, et. al. Iatrogenic operative injuries of abdominal
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the portal vein: The role of acute ligation. Ann Surg 1979; 189:
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19. Pessaux P, Varma D, Arnaud JP. Pancreaticoduodenectomy:
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accuracy of EUS for vascular invasion in pancreatic and
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CHAPTER 11
Pelvic Exenteration
Puneet Dhar
Unnikrishnan G
INTRODUCTION
The procedure of pelvic exenteration was originally
described by Brunschwig and was practiced as a
palliative resection for advanced gynecological
malignancies. This procedure is now frequently used
in rectal cancer involving anterior urogenital
structures in highly selected patients. Considering its
magnitude, it is probably best done only to effect cure,
where lesser procedures would not suffice.
INDICATIONS
Pelvic exenteration is indicated in locally advanced
cancer with multivisceral involvement within the
pelvis, i.e. malignancies of
• Rectum
• Cervix
• Uterus
• Upper vagina
CONTRAINDICATIONS
• Involvement of lateral pelvic wall or sacrum
• Presence of distant or extrapelvic metastasis
• Short anticipated life span
• Significant comorbidity
PREOPERATIVE EVALUATION
• Complete colonoscopy to rule out synchronous
lesions.
Pelvic Exenteration 161
• Imaging to assess distant and local spread and

assess respectability – usually CT scan of pelvis and
abdomen. Occasionally, a PET scan may be needed
to confirm absence of extra abdominal malignancy
• Preoperative CEA evaluation to form the base line
for follow up.
• In selected cases, e.g. transmural or bulky disease,
preoperative neoadjuvant therapy may be
required.
SURGICAL TECHNIQUE
Preparation
• Mechanical bowel preparation on the day prior to
surgery using oral peglec or exelyte with liquids
• Preoperative chest physiotherapy and breathing
exercises.
• Potential stoma sites must be marked out and the
patient counseled by an enterostomal therapist.
Low molecular weight heparin for prevention of
thromboembolism (e.g. Dalteparin 2500 IU or
Enoxaparin 20 mg s/c) 12 hours prior to surgery.
• Preoperative antibiotics at anesthesia induction,
e.g. cefuroxime 1.5 g with metronidazole 500 mg
IV. This should be repeated 4 hourly during
surgery.
Position
• Under GA with epidural catheter (for postopera-
tive pain control).
• Thighs are abducted in Trendelenburg’s position.

The lower limbs are supported by Lloyd-Davies
leg rests.
• Flexion at hip to maximum of 15o. A pad is placed
beneath the sacrum so that the coccyx is one inch
beyond this pad.
Incision
• Long lower midline
Steps of Operation
• Bladder is catheterized and emptied. The catheter
(and external genitalia in males) is taped to the
thigh. Ureteric catheters are inserted in reopera-
tions, if there is bulky disease in the pelvis, and/
or after radiotherapy.
• The anus is closed with a heavy purse string suture
(double if the preparation is poor).
• A self-retaining retractor with an adjustable pelvic
blade is used to wider the exposure. In females,
the uterus is temporarily sutured anteriorly.
• Resectability is assessed. Absence of gross distant
disease and synchronous lesions in the rest of the
colon is confirmed.
• A large moistened sponge is placed along the root
of the mesentery from the ileocaecal junction to the
DJ flexure and the small bowel is packed up and
to the right. This will expose the retroperitoneum
to the level of the 3rd part of the duodenum and

the origin of the Inferior mesenteric artery.
• Sigmoid and descending colon is mobilized in
standard fashion after division of any adhesions
of the sigmoid colon to the parietes. The left leaf
of the sigmoid mesocolon is opened to expose the
left ureter as it crosses the iliac artery at its
bifurcation on the pelvic brim. The right ureter is
usually visible under the peritoneum in all but the very
obese. Peritoneum is incised on the left, as it reflects
on to the posterior abdominal wall from the
sigmoid mesocolon and upwards to the root of the
IMA and down into the pelvis. The plane on the
right side is joined to the previous plane by
dissection between the IMA and the aorta.
• Ligation of the inferior mesenteric pedicle may be
flush, after the take off of the left colic artery or
after the take off of the 1st sigmoid branch. A high
ligation of the IMA does not confer any survival
advantage to the patient, it only improves staging.
If preservation of the sphincters is not on, the
sigmoid colon is transected now. The level of
transection should ensure that there is no tension
on the stoma, at the same time a redundant colonic
loop within the abdomen is avoided. The fatty and
areolar tissue inferior to the ligated IMA can be
swept off the retroperitoneum with sharp
dissection to reach the sacral promontory.
• Posterior pelvic dissection is done sharp with

cautery or scissor by developing the plane within
the pre-sacral connective tissue just anterior to the
Waldeyer’s fascia. Care should be taken not to
breach the fascial envelope of the mesorectum.
This is an avascular plane and bleeding is
encountered only if the plane strays anteriorly or
posteriorly. Bleeding from the pre-sacral venous plexus
can be troublesome and is best avoided rather than treated.
In case of bleeding firm packing is better than repeated
attempts at cauterization or suturing. If it persists, thumb
tacks may be pressed into bone or loose muscle cauterized
into the bony origin of the vein.
• Anterior pelvic dissection begins where the ureter
crosses over the iliac vessels. The leaves of the
peritoneum are held up with Allis forceps and they
are lifted up to allow dissection of the paravesical
space. The round ligament and the infundibulo-
pelvic ligaments in the female will have to be ligated
prior to this step. The plane is developed downwards
to reach below the prostate or to the urethra in
the female. The superior vesical artery and the
uterine artery in the female is seen passing medially
in the paravesical space and is ligated individually.
The ureter is dissected out and transected in the
pelvis bilaterally with a safe tumor free margin.
• Rectum is retracted to either side and the opposite
lateral ligament is displayed and cut sharply and
bleed from the middle rectal vessels is controlled
by using electrocoagulation or a ligature. Once the

anterior and lateral mobilizations and the posterior
mobilization of the rectum are complete, the rest
of the dissection can be carried out from the
perineum.
• The level of transection of the urethra mandated
by the level of involvement of the urinary tract by
the tumor. In case where the membranous urethra
is suspected to be involved by the tumor, the
pelvic diaphragm and part of the bulbar urethra
(in male) can be included in the resection specimen
from the perineum.
• Complete vaginectomy is usually not needed for
Ca rectum. The median portion of the posterior
vaginal wall can be included within the resection
by extending the perineal incision anteriorly.
• An elliptical incision extending to a midpoint of
the perineum anteriorly and the tip of the coccyx
posteriorly is made. Skin is deepened and the anus
is drawn to either side to enter the ischiorectal
fossa to divide the fat. The anococcygeal raphe is
divided and the anus is retracted anteriorly to
expose the Waldeyer’s fascia. This fascia is divided
to allow the perineal operator to enter the pelvis.
The inferior rectal vessels are encountered laterally
and controlled with cautery. The ileococcygeus is
divided by the cautery to free the anus and rectum
on all aspects except the anterior, where it connects
with the level of urethral division.
• The rectum is now drawn out off the perineal

wound.
• A single loop stoma with one end draining the
urinary tract and other the fecal stream is used.
• The colonic end is stapled and over sewn with non-
absorbable sutures. Two 0.5 cm nicks are made on
the medial border of the sigmoid colon and the
spatulated tips of the ureters are tunneled
subserosally and a mucosa-to-mucosa anasto-
mosis is done with 3-0 vicryl (leaving ureteric
catheters).
• The external stoma is constructed by taking out a
loop of colon, about 20 cm proximal to the ureteric
anastomosis. This loop stoma is almost completely
divided to allow near complete separation of the
urinary and bowel effluents.
Closure
The abdomen is lavaged and hemostasis is confirmed.
The pelvis is drained through the perineum or more
commonly abdominally.
• Abdomen is closed using single layer mass closure
with no.1 prolene or no. 1 looped ethilon and skin
by clips.
• Perineum is closed in two layers i.e., inner
interrupted 3-0 vicryl and skin with subcuticular
monocryl.
POSTOPERATIVE CARE
• Constant and regular monitoring of vitals and
intake output recordings are made. Fluid and
electrolyte replacement is done as required.
• Patient is retained in the surgical intensive care
unit for the first 24 hours. Invasive hemodynamic
monitoring is done only when indicated by co-
morbidities.
• Stoma examination and care (Initial use of
transparent temporary stoma legs).
• Active ambulation is done as soon as possible.
• Urinary catheter is removed on 7th day.
• Anticoagulation is continued for 2 weeks.
• DVT prophylaxis is continued for 2 weeks.
• Nasogastric tube is usually not required. As soon
as stoma movement is seen, and ileus regresses –
feeding is commenced.
• Drains are removed in two to four days.
• Prophylactic antibiotics are continued for three
doses after closure.
• Care of ureteric catheters, which are retained as
stents across the urinary anastomosis for about
one week.
• Urine microscopy and cultures, for any features of
sepsis.
• Regular electrolyte monitoring to rule out possible
hypochloremic acidosis and stomal pouch calculi.
POSTOPERATIVE COMPLICATIONS
• General
• Hemorrhage
• Ileus
• Intestinal obstruction
• Wound infection
• Related to perineal wound
• Hemorrhage
• Infection
• Skin necrosis
• Nonhealing perineal sinus
• Perineal hernia
• Local recurrence
• Colostomy related
RESULTS
• Postoperative mortality may be upto 5% and
morbidity is 50% to 75%.
• Overall 5 year survival exceeds 50%.
• Long-term survival depends on histological margins,
age, grade and stage of tumor (especially lymph
nodal status),
• Use of preoperative chemo- and radiotherapy also
effects the outcome.
• Gynecological have adverse prognosis tumors and
presence of recurrent disease.
BIBLIOGRAPHY
1. Avradopoulos KA, Vezeridis MP, Wanebo HJ. Pelvic
exenteration for recurrent rectal cancer. Adv Surg 1996; 29:215-
33.
2. Berek JS, Howe C, Lagasse LD, Hacker NF. Pelvic exenteration
for recurrent gynecologic malignancy: Survival and morbidity
analysis of the 45-year experience at UCLA. Gynecol Oncol
2005; 99:153-9.
3. Carter MF, Dalton DP, Garnett JE. Simultaneous diversion of
the urinary and fecal streams utilizing a single abdominal
stoma: The double-barreled wet colostomy. Jour Urol 1989;
141:1189-91.
4. Ike H, Shimada H, Ohki S, Yamaguchi S, Ichikawa Y, Fujii S.
Outcome of total pelvic exenteration for locally recurrent rectal
cancer. Hepatogastroenterology. 2003;50:700-3.
5. Vermaas M, Ferenschild FT, Verhoef C, Nuyttens JJ, Marinelli
AW, Wiggers T, Kirkels WJ, Eggermont AM, de Wilt JH. Total
pelvic exenteration for primary locally advanced and locally
recurrent rectal cancer. Eur Jour Surg Oncol 2007; 33:452-8.
6. Wydra D, Emerich J, Sawicki S, Ciach K, Marciniak A. Major
complications following exenteration in cases of pelvic
malignancy: A 10-year experience. World Jour Gastroenterol
2006; 12:1115-9.
CHAPTER 12
Radical
Cytoreductive
Surgery for
Pseudomyxoma
Peritonei
Puneet Dhar
Ramachandran Menon
INTRODUCTION
Pseudomyxoma peritonei (PMP) is the intraperitoneal
spread of mucin-secreting cells that originate from the
appendix or rarely from ovarian mucinous tumors
causing recurrent abdominal masses and bowel
obstruction. Gelatinous implants can occur over any
peritoneal surfaces causing a mucinous ascites (jelly
belly) and is considered at least of borderline
malignant potential. It is currently believed to be a
disease of MUC 2 expressing goblet cells (causing
voluminous deposits of extracellular mucin with
mucin to cell ratios exceeding 10:1. Cytoreductive
surgery (CRS) using peritonectomy procedures can
cure or bring relief lasting years. It is ideally
complemented by intraperitoneal chemotherapy and
hyperthermic techniques to prevent tumor recurrence.
INDICATIONS
• Pseudomyxoma peritonei– invariably low grade
mucinous appendiceal tumors
• Peritoneal carcinomatosis due to appendiceal
malignancy, colorectal malignancy, ovarian
malignancy
• Rarely peritoneal carcinomatosis due to gastric or
small bowel malignancies, sarcomatosis (GISTs) or
mesothelioma.
Radical Cytoreductive Surgery 173
CONTRAINDICATIONS
• Extra abdominal metastasis or massive retroperi-
toneal lymph nodes
• Uncontrollable or unresectable liver metastasis
• Extensive, invasive carcinomatosis that cannot be
controlled with CRS
• Poor performance status
• Carcinomatosis of the pancreatic and hepato-
biliary origin.
STAGING
Gilly’s Staging
Gilly’s staging based on the dimension of tumor
granulations
Stage 0—No macroscopic disease
Stage I—Malignant implants < 5 mm in the greatest
dimension, localized in one part of the abdomen
Stage II—Malignant implants < 5 mm, throughout
abdomen
Stage III —Malignant implants 5 mm- 2 cm in greatest
dimension
Stage IV—Large malignant cakes (larger than 2 cm in
dimension).
Peritoneal carcinomatosis index (PCI) has been
described by Jacquet and Sugarbaker (Fig. 12.1). The
size of the largest implant is scored in each
abdominopelvic region on a scale 0 to 3.
Fig. 12.1: Peritoneal carcinomatosis index
Abdomen and pelvis is divided into 13 regions

(0-12) and lesions are scored according to the size
(0-3)
Score 0 - No tumor
1 - = < 5 mm
2 - 0.5-5 cm
3 > 5 cm or tumor confluence
The total score of PCI can vary from 0-39. Survival
results are significantly better when the PCI is lower
than 16. If the score more than 20 these patients
require mostly palliation.
PREOPERATIVE PREPARATION
• Liquid diet on the day prior to surgery.
• Bowel preparation with Peglec or Exelyte solution.

• Adequate hydration
• Stoma sites to be marked before surgery, as it may
be required to be done
• Skin preparation from mid chest to mid thigh.
• Low molecular weight heparin from day prior to
surgery to prevent venous thromboembolism
• Staging laparoscopy may be beneficial in selecting
patients unlikely to benefit from the surgery.
SURGICAL TECHNIQUE
Position
• Patient is placed in modified lithotomy position
(Fig. 12.2)
Fig. 12.2: Position of patient
• Large calibre nasogastric tube is placed in the

stomach.
• Thromboembolic deterrent-TED ® stockings of

appropriate size should be applied to prevent
DVT.
• A hyperthermia blanket (Bair Hugger®) is placed
over chest andz lower limbs to prevent hypothermia
• Insertion of Foley’s catheter with urometer to
assess the hourly urine output.
Incision
• Midline vertical incision from xiphoid to pubis
• Thompson type or ring type Self-Retaining
Retractor is placed to expose the abdomen widely.
Steps of Operation
Cytoreductive surgery essentially includes six
different peritonectomy procedures to resect cancer
on visceral intra-abdominal surfaces or to strip cancer
from parietal peritoneal surfaces. These procedures
include:
• Parietal peritoneal stripping from anterior abdo-
minal wall
• Greater omentectomy–splenectomy
• Stripping of the peritoneum from left and right
hemidiaphragms
• Cholecystectomy and hepatoduodenal ligament
clearance
• Stripping the floor of omental bursa ± antrectomy/
gastrectomy
• Pelvic peritonectomy with resection of uterus and

recto-sigmoid colon.
The standard tool used to dissect tumor from the
normal tissues is a electro-surgical hand piece. The
focal point for further dissection is marked and strong
traction applied. All blood vessels are cauterized
before their division. Diffuse oozing from the parietal
surface can be arrested with argon beam coagulator.
CUSA is another useful tool for peritonectomy.
Parietal Peritoneal Stripping from Anterior

Abdominal Wall
• To begin, the peritoneum that is present on the
edge of the abdominal incision is stripped off from
the posterior rectus sheath
• For a better hold, artery clamps are positioned
approximately every 10 cm allowing traction to be
achieved on the tumor specimen. This becomes
easier towards the paracolic sulcus (line of Toldt)
as the peritoneum is loosely attached to the
underlying fatty tissue.
Peritoneal Stripping Beneath the

Hemidiaphragms
• The left upper quadrant peritonectomy involves
stripping of all tissue from beneath the left
hemidiaphragm to expose diaphragmatic muscle,
left adrenal gland, superior aspect of pancreas, and
the cephalad half of Gerota’s fascia
• Left gastric artery should be preserved as the sole

blood supply to the stomach
• On right side, the tumor nodules with the
peritoneum is stripped off from the muscular
surface of the diaphragm and continues until the
bare area of the liver is encountered. Here, tumor
is removed off with the Glissonian sheath (sub
Glissonian dissection)
• Isolated patches of tumor and bleed on the liver
surface controlled by diathermy or argon beam
coagulation
• Right perirenal fat is cleared, preserving right
suprarenal
• Excision of a portion of the hemidiaphragm is
occasionally required for deeper tethering of
tumor to the diaphragm. The residual defect is
then closed with interrupted non-absorbable
sutures.
Omentectomy and Splenectomy

• Greater omentectomy frees the midabdomen of
large tumor volumes. The omentum is separated
from the transverse colon using cautery after
ligating all major vessels
• This dissection continues beneath the peritoneum
that covers the transverse mesocolon to expose the
pancreas
• Right and left gastroepiploic vessels and the short
gastric vessels are ligated and divided
• With traction on the spleen, the anterior fascia of

the pancreas is elevated from the gland by cautery
to expose the splenic artery and vein. At the tail
of pancreas, these vessels are ligated and divided.
Splenic flexure of colon is lowered down and
peritoneum from the lateral surface of the spleen
is lifted up. Splenectomy is completed.
Cholecystectomy, Hepatoduodenal Ligament

and Omental Bursa Strip and Antrectomy
• Right gastric vessels are ligated and divided. The
gallbladder is dissected off from liver. Cystic
artery ligated and divided. The cancerous tissue
that covers the porta hepatis is stripped from the
base of the gallbladder bed toward the duodenum.
Care is taken to preserve the left accessory hepatic
artery if present.
• Lesser omentum is resected from liver base upto
the left gastric vessels.
• After clearing the left part of the caudate lobe, the
vena cava is visualized directly beneath it. Loose
fibrous tissue is lifted off from the vena cava and
the right crus of diaphragm are skeletonised.
Ascending and descending branches of the left
gastric artery is preserved.
• During this procedure multiple branches of the
vagus nerve to antrum of the stomach are divided.
• Antrectomy with Bilroth II gastrojejunostomy
reconstruction is done, especially if this area is
caked with tumor.
Pelvic Peritonectomy and Sigmoid Colectomy

(Fig. 12.3)
• Pelvic peritoneum is stripped from the posterior
surface of the lower part of the abdominal wall
incision, exposing the peritoneal surface of the
rectus muscle. Peritoneum from the antero-lateral
aspect of the bladder is stripped off by dividing
the urachus. Round ligaments are divided as they
enter the internal inguinal ligament.
• Peritoneal incision around the pelvis is completed
by dividing the peritoneum along the pelvic brim.
Both ureters are protected. IMA is divided at its
origin and the stump doubly ligated.
Fig. 12.3: Pelvis after peritonectomy

• In women, an extra peritoneal suture ligation of

the uterine arteries is done just above the ureter
and close to the base of the bladder. The bladder
is moved gently off the cervix, and the vagina is
entered to complete the hysterectomy.
• The vaginal cuff anterior and posterior to the
cervix is divided and the perirectal fat inferior to
the posterior vaginal wall (beneath the peritoneal
reflection) is excised. This ensures that all tumors
that occupy the cul-de-sac are removed intact with
the specimen.
• The mid rectal wall is skeletonized and divided
with a roticulator or linear stapler to facilitate a
double stapled anastomosis.
• Sigmoid and left colon are mobilized completely.
Specimen (recto-sigmoid, entire uterus with cervix
and both ovaries in females, pelvic peritoneum
along with the tumor tissue), is removed by
dividing the sigmoid at a convenient plane where
vascularity is adequate. IMV may be ligated and
divided as high as possible to reduce tension in
the sigmoid mesentery.
Vaginal Closure and Colorectal Anastomosis

• Interrupted absorbable sutures are used to close
the vaginal cuff
• A circular stapling device is passed into the rectum,
and the trocar is penetrated through the staple
line. A 2-0 prolene suture is placed in a purse-
string fashion to secure the staple anvil in the

proximal sigmoid colon. The body of the circular
stapler and anvil are linked, and the stapler is fired
to complete the low colorectal anastomosis.
• For a secure anastomosis one should ensure the
completeness of both doughnuts. Air insufflation
into the rectum using a Duval’s pump (while the
pelvis is drenched with water) can confirm an air
tight anastomosis.
• A hand is passed beneath the sigmoid colon to
ensure lack of tension on the stapled anastomosis.
Closed drains are placed in the dependent
portions of the abdomen. This includes the right
subhepatic space, the left subdiaphragmatic space, and
the pelvis. A Tenckhoff catheter (or Quinton spiral
peritoneal dialysis catheter) is placed through the
abdominal wall, positioned beneath small bowel loops
for postoperative intraperitoneal chemohyperthermia
(IPCH) using Mitomycin C at 39-42° C for 1-2 hours
and followed up with Intraperitoneal chemotherapy
using 5FU.
ASSESSMENT OF COMPLETE CYTOREDUCTION

The residual tumor nodule remaining after
cytoreduction can predict prognosis by estimating the
possibility of cancer eradication.
CCS 0 No peritoneal seedlings present after
cytoreduction
CCS 1 Tumor nodules persisting after cyto-

reduction are less than 2.5 mm dm.
CCS 2 Tumor nodules between 2.5mm and 2.5 cm
in dm
CCS 3 Nodules greater than 2.5 cm or confluence
of unresectable tumor nodules.
COMPLICATIONS
• Bowel perforation and anastomotic leak, if
combined with IPCH, are invariably lethal.
• Paralytic ileus
• Biliary leak
• Pancreatitis
• Intra-abdominal bleeding
• Wound dehiscence
• Pulmonary embolism
• Renal failure and hematological toxicity.
RESULTS
• Average 5 year survival after Cytoreductive
surgery for PMP with IPCH is 50%.
• It is 80% in those with complete cytoreduction
(especially if repeat procedures are done for
recurrent disease) compared to 20% with
incomplete cytoreduction.
• Mortality is 2% in best hands.
• More than 10% need re-exploration for
complications.
• Overall rate of grade III or IV complications is

about 40%.
• Overall quality of life after surgery decreases short
term but returns to baseline or better in 3-6 months
and in 90% of long-term survivors, quality of life
with functional assessment compares favorably
with age matched controls.
BIBLIOGRAPHY
1. Esquivel J, Sticca R, Sugarbaker PH, et al. Cytoreductive
surgery and hyperthermic intraperitoneal chemotherapy in the
management of peritoneal surface malignancies of colonic origin:
a consensus statement. Ann Surg Oncol 2007;14:128-33.
2. Gilly FN, Carry PY, Sayag AC, et al. Regional chemotherapy
(with mitomycin C) and intra-operative hyperthermia for
digestive cancers with peritoneal carcinomatosis. Hepatogastro-
enterology 1994;41:124-9.
3. Jacquet P, Sugarbaker PH. Clinical research methodologies in
diagnosis and staging of patients with peritoneal
carcinomatosis. Cancer Treat Res. 1996;82:359-74.
4. Murphy EM, Sexton R, Moran BJ. Early Results of Surgery in
123 Patients with Pseudomyxoma Peritonei from a Perforated
Appendiceal Neoplasm. Dis Colon Rectum 2007;50:37-42.
5. Sugarbaker PH. New standard of care for appendiceal epithelial
neoplasms and pseudomyxoma peritonei syndrome? Lancet
Oncol 2006;7:69-76.
6. Sugarbaker PH. Peritonectomy procedures. Ann Surg 1995; 221:
29-42.
CHAPTER 13
Surgery for Complex

Anal Fistula
Ashok Kumar
INTRODUCTION
An abscess and fistula is the sequel of the same
problem, i.e. the infection of the anal gland. While an
abscess is the acute presentation, the fistula represents
the chronic form. Many fistulae start as an abscess,
while others develop insidiously, almost all of them
are crypto glandular in origin. Majority of fistula can
be treated easily by an experienced hand. Fistula
surgery, by and large is not a big surgical problem
but, in a small percentage of cases, it poses a lot of
trouble to the patient both physical and psychological.
At the same time it becomes a surgical challenge to
the treating person, because of recurrence and
incontinence.
It is important to know beforehand the following
details in order to deal with such fistulae
• Anatomy of the anal canal and the anal sphincter
• Pathology of the fistula
• Classification
• Available surgical options
ANATOMY OF THE ANAL CANAL AND ANAL

SPHINCTER (FIG. 13.1)
A. External anal sphincter (ES): This is continuation
of pelvic floor musculature, comprised of levator
ani complex and puborectalis, and is voluntary in
nature. Division of this musculature can lead to
incontinence for stool.
Surgery for Complex Anal Fistula 187
B. Internal anal sphincter (IS): This is a continuation

of the inner circular muscle layer of the lower
rectum, which is thickened in the area of the anal
canal, and is involuntary in nature. Division of this
can lead to flatus incontinence.
Fig. 13.1: Anatomy of the anal canal
PATHOLOGY OF FISTULA
The specific fistulas are either due to tuberculosis,
Crohn’s disease, trauma, carcinomas and/or the
diverticular diseases of the colon. In a recurrent and
nonhealing fistula, one should also keep the other
possibilities in the differential diagnosis like—perianal
sebaceous cyst, hyderadenitis suppurativa and post-
rectal dermoid.
CLASSIFICATION
The most widely used classification for fistula in ano
is by Park et al 1976, which is as follows (Fig. 13.2).
• Trans-sphincteric
• Intersphincteric
• Suprasphincteric
• Extrasphincteric
Fig. 13.2: Park’s classification
The fistulas may, however extend (secondary

track) in the intersphincteric plane, the ischiorectal
fosse and the para rectal (supralevator) spaces (Fig.
13.3).
Fig. 13.3: Extension of infection
High Vs Low Fistula and Complex Fistula

There is no definite or uniform definition. The des-
cription is based on the location of internal opening,
i.e. if the opening is at the level of anal valve, it is
low or if it’s above, is high fistula. However, it is
usually not possible to find an internal opening in all
cases, and hence these terminologies become
infractions.
The complex fistulae are those which are difficult
to treat and have a high chance of recurrences.
These are—
• Fistula occurs after primary surgery
• Fistula with multiple external openings
• Presence of induration above puborectalis on
P/R examination (Extrasphincteric or supralevator)
• Probe passing vertically upwards instead of

towards the mid anal canal (supralevator) from
external opening
• High trans-sphincteric fistula
CAUSES OF RECURRENT FISTULA

• Failure to identify and lay open the primary tract
• Unidentified secondary track
• Iatrogenic (during drainage of ischiorectal abscess)
• Specific anal/perianal pathology/disease
OBJECTIVES OF TREATMENT
• To define the fistula anatomy
• To drain an associated abscess
• To eradicate the fistula track
• To prevent recurrence
• To preserve continence and sphincter integrity
ASSESSMENT OF ANAL FISTULA

• Locate the internal opening
• Identify the external opening
• Define the course of primary track
• Confirm the presence of secondary extensions
• Find out any other underlying disease compli-
cating fistula
Methods of Assessment
• History and clinical examination
• Fistulography—very limited role

• Endorectal USG—Definite role in complex anal
fistula as first line of investigation and recurrent
fistula as an adjunct to MRI.
• MRI—Accurate method of imaging fistula.
Investigation of choice for complex and recurrent
fistula.
• CT scan-Thin slice spiral CT, when MRI is not
available or contraindicated.
• Anal manometry Selective role (sphincter saving
surgery, patient with already compromised
sphincter).
Clinical Evaluation
• History of previous perianal abscess and surgical
intervention
• Underlying disease—TB, Crohn’s DM, HIV
• Incontinence
• Constipation
• Bleeding
• Immunosuppressant patient
• Per-rectal digital examination
• Look for external opening, and its position
(apply Goodsall’s rule to predict the position
of international opening – applicable in most of
the posterior fistula, and to a lesser extent for
anterior fistula)
• Palpate for primary tack with lubricated finger
• Palpate for internal opening as a small

induration (always compare from opposite site)
• Correlate the position of internal opening in
relation to puborectalis muscle (ask patient to
squeeze)
SURGICAL TECHNIQUE
Based on the surgeons preference and comfort
Surgery can be performed in one of the following
position
I. Lithotomy position
II. Prone Jack-Knife position
III. Sim’s lateral position (when prone jack-knife
position is contraindicated, e.g. in obese patients)
Anesthesia
The aim of anesthesia should be good muscle relaxant
and early postoperative pain control. If the plan is first
examination under anesthesia (EUA) and then decide
about surgery or no surgery, best is to avoid relaxant.
Once the surgery is decided upon then relaxant are
given. This helps to assess the tone of the sphincter.
Local infiltration, field block or regional anesthesia
can be used for superficial fistula.
High and complex fistula in ano are better dealt
under general/regional anesthesia.
Bowel Preparation
• No special preparation is required except a mild
laxative a night before the day of surgery or a
phosphate enema, the morning of the surgery.
• However, if an advancement flap is planned, a full
bowel preparation with polyethylene glycol (PEG)
a day before surgery would be better.
Methods of Localization/Identification of
Internal Opening
• Palpation
• Anoscopy
• Pressure over external opening – look for any
discharge during anoscopy
• Partial coring around the external opening and
traction on it – look for puckering during anoscopy
• Dye injection through external opening (methylene
blue or India ink)
• Injection of hydrogen peroxide through the
external opening (look for air bubble)
• Milk
• Hydrogen peroxide with blue dye
• On table endo USG
• On table fistulography
Surgical Options in Complex/High Fistula in Ano

1. Setons (Table 13.1)
• Loose setons – drainage
• Cutting setons – Single stage

• Two stage (staged fistulotomy)
• Initial seton followed by fistulotomy
• Partial fistulotomy followed by seton
• Ksharsutra - Indian medicated thread
2. Fistulectomy and sphincter repair
3. Advancement flap (where fistulotomy can lead to
incontinence)
4. Fibrin Glue
Treatment of Complex/High Fistula in Ano

As these fistulae are difficult to treat, the aim of
treatment should be
1. control the sepsis first
2. deal with secondary extensions
3. take care of primary track
If there are underlying abscesses, the basic outline
for drainage is as follows:
Abscess Route of Drainage (Fig. 13.4)
Supralevator abscess Through ischiorectal fosse

Extra-sphincteric abscess Into the rectum/loose seton
Horse-shoe extension Behind the rectum
Setons and Methods for its Application

There are various techniques of seton use for fistula
in ano. These are drainage setons, cutting setons,
chemical setons and staged seton fistulotomy.
The various materials used are–silk or any
Fig. 13.4: Routes of drainage of pararectal abscesses
Table 13.1: Layout plan for type of fistula and surgical options
Type of fistula Surgical options
High trans- Fistulectomy

sphincteric Advancement Flap
Seton
Suprasphincteric Division of skin and lower parts of internal and

external sphincter + seton around the sphincter
complex
Staged cutting seton — Initial seton ( which coverts
high into low fistula) followed by fistulotomy
advancement flap
Excision of the tract upto external sphincter
opening + Internal sphincterotomy + Seton around
the external sphincter
Extraspincteric Usually abdominal approach required, as common

cause are diverticular, Crohn’s and radiation
As Rx option in suprasphincteric fistula
Closure of the internal opening and external
drainage
nonabsorbable suture material (nylon, ethibond,

prolene), vessel loop, rubber band, silastic catheter,
penrose drain and steel wire. Choice of material used
depends on surgeon. Thin silastic tubing (vessel loop)
has advantages of easy railroading during
replacement.
Indications for Cutting Seton

1. High trans-sphincteric fistula
2. Complex fistula-in-ano
Specific Indications
• To identify and promote fibrosis around a complex
fistula that encircles most or all the sphincter
• To mark the site of trans-sphincteric fistula in case
of severe sepsis and distorted anatomy
• Anterior trans-sphincteric fistula
• Crohn’s disease, AIDS, HIV patients
Technique (Fig. 13.5)

• Identify the external and internal opening.
• Pass a fistula probe.
• Excise the lower portion of the internal sphincter
and the skin upto the external opening.
• Seton (material of choice) is threaded, and ends
are tied.
• Multiple knots are given to avoid premature
release.
• Setons are tied (changed) at regular interval (7 to

14 days) either in OPD clinic or under anesthesia
depending on the situation.
• During the course of follow up either the seton is
cut through completely or convert high fistula into
low fistula, where staged fistulotomy can be
considered.
• The proximal fistulotomy done by seton heals by
fibrosis, avoiding the separation of the sphincter
muscle, however, possibility of minor incontinence
is always there.
Fig. 13.5: Application of seton
Advancement Flaps
Indications
• Anterior fistula in women
• High trans-sphincteric fistula

• Supra-sphincteric fistula
• Multiple previous sphincter operations
• Complex fistulae
Contraindications
• Acute presentation of fistula
• Rectal diseases (Neoplasia, Crohn’s, radiation
proctitis)
• Very large fistulous opening (>3 cm, relative
contraindication)
• Multiple previous surgery making difficult to raise
the flap
Bowel Preparation
Full bowel preparation is required

Anterior fistula—Prone Jack-Knife position
Posterior and lateral fistula—Lithotomy
Technique
The flap usually comprises of mucosa, submucosa and
internal sphincter.
However, there are various modifications which
are as follows:
• Full thickness rectal flap
• Partial thickness
• Curved incisions
• Rhomboid flaps
• With or without closure of the defect in the
sphincter muscles
Steps of Operation
• Identify the internal opening by passing the
anoscope (Fig. 13.6)
• Mark the flap with cautery: 5-10 mm below the
internal opening and
• 10-15 mm on either sides (Fig. 13.7)
• Infiltrate the intersphincteric plane with 0.5%
lidocaine or saline with 1: 400,000 solution of
adrenaline
• Start mobilization of the flap laterally which is
relatively virgin area
• Raise the flap proximally up to the lower rectum
(Fig. 13.8)
• Distal end of flap should be next to the internal
opening
• After sufficient mobilization, the distal end
including internal opening is excised
• Any remnant of the primary track within the
intersphincteric plane is excised
• Hemostasis is achieved
• Flap is advanced over the defect and secured with
sutures (3/0 PDS or 2/0 vicryl, interrupted)
encompassing the internal sphincter in the flap and
the internal sphincter of the remaining anal canal
(Fig. 13.9).
Fig. 13.6: Advancement flap


Dissection of primary tract, starting from external

opening up to the external anal sphincter is not
absolute necessary. However, this tract should be
drained by passing a tube from external opening right
upto underneath the flap, which is usually removed
after 3 to 5 days depending on the amount and
nature of discharge.
Post Op care: Patient is put on liquid diet for five
days and once orally allowed, added with bulk stool
forming agent.
Fibrin Glue in Fistula in Ano

Fibrin glue is very simple to use because it does not
affect the future intervention on anal canal with no
or minimal morbidity. Success rate in the published
series varies from 0 to 100% (in all types of fistulae),
in short follow up period, with an average of 50%.
Fibrin glue is a mixture (fibrinogen solution) of
fibrinogen, factor XIII, fibronectin and aprotinin.
Fibrin glue is a tissue sealant that stimulates
physiological clot formation. Activation is initiated by
mixing the fibrinogen solution with thrombin and
calcium ions. The fibrinogen is broken into fibrin
monomer, which loosely aggregates to form a soluble
clot. Same time the thrombin and calcium activate the
factor XIII (F XIIIa), which in turn cross link the
soluble clot into an insoluble and stable form.
The fibrinolysis is prevented by aprotinin. The F XIIIa
also helps in cross-linkage of the fibronectin, and
fibrin to the surrounding collagen tissue. Lysis of the

fibrin clot is caused by plasmin, which takes place
within 7-14 days. By this time, the collagen synthesis
has already started by fibroblast, which promotes the
subsequent process of healing. Autologous and
commercial, both form of fibrin glue has been used
with almost similar success rate (46% vs 36%
respectively).
Bowel is prepared to avoid early post op bowel
movement, which may cause glue dislodgement.
Perioperative antibiotics are recommended.
Method of Application
• Identify the external and internal opening by
digital examination and anoscopy.
• Curettage/abrasion of granulation tissue from tract
done
• Close the internal opening with the help of finger/
gauze
• Both the components of the solution are warmed,
drawn in two syringes, placed in a two syringe
clip, having a common plunger.
• A double lumen Y–connector joins the two
syringes. The tip of the Y–connector is connected
to a single lumen connector, which is introduced
into the fistulous track through external opening.
• The injection is performed slowly, which leads to
mixing of the two components at the tip and glue
formation.
• The catheter is withdrawn slowly.

• Three to five min is required for the glue to adhere
the surrounding tissue (Table 13.2).
Table 13.2: Results of Fistula Surgery (high/ complex fistula)
Advancement flap
Author Number FUP Outcome

Healing Recurrence Incontinence
Jun, 1999 40 17 95% 2.5% 0%

Ortiz, 2000 103 12 93% 7% 8%
Amin, 2003 83 19 83% 11% 0%
FUP : Median follow up in months
Loose seton

Recurrence Incontinence%
Minor Major
Thomson,1989 34 55 44% 17 0
Williams, 1991 14 24 14% 36 8
Buchanan, 2004 14 142 79% ? ?
Loose seton as a part of staged fistulotomy

Recurrence Incontinence%
Minor Major
Parks & Sitz, 1976 80 >12 9 % 17 0

Ramanujam, 1983 45 — 2 % 1 0
Williams, 1991 24 24 8% 54 4
Garcia-Aguilar, 47 33 8% 50 24
1998
Outcomes of cutting seton
Author number FUP Outcome

Recurrence% Incontinence%
Minor major
Hanley,1978 35 ? ? ? ?
Misra & Kapur, 59 22 4 0 0
1988
Williams, 1991 13 24 0 54 7
Garcia-aguilar, 12 27 6 67 25
1998
Isbister, 2001 47 13 2 36 11
Zbar, 2003 34 12 6 13 0
Mentres, 2004 20 12 5 20 0
Outcome of fistula surgery–based on type of fistula

(Sygut et al ref 8, n = 300, prim fistula 242, rec fistula 58)
Fistula type n Procedure Incontinence Recurrence
(%) (%)
Trans-sph 99 Partial fistulectomy 13.3 16.8

+
Cutting seton
Supra-sph 48 i) partial fistulectomy(40) 22.9 29.1
+
Cutting seton
ii) Advancement flap(6)
iii) Fibrin glue (2)
Extra-sph 15 Closure of internal opening 30 40
+
Drainage of track
Follow up: Mean 4.2 year (5 month-11.6 year)

Incontinence: For gas and/or stool
BIBLIOGRAPHY
1. Hammond TM et al. Fibrin glue in the management of anal
fistulae. Colorectal Disease 2004; 6: 308-19.
2. Hancock BD, Anal Fissures and Fistulas. BMJ 1992; 304,
904-7.
3. Mc Courtney, JS Finlay IG. Setons in the management of fistula-
in-ano. Brit Jour Surg 1995; 82: 448-52.
4. Parks AG, Gordon PH, Hard castle JD. A classification of
Fistula-in-ano. Brit Jour Surg 1976; 63: 1-12.
5. Phillips, RK, Lunniss, PJ (eds): Anal Fistula. London; Chapman
and Hall, 1996.
6. Rickard Mathew JFX. Anal abscesses and fistulas. Aus NZ.
Jour Surg 2005; 75: 64-72.
7. Sygut A Zajdel R, et al. Late results of treatment of anal fistulas.
Colorectal disease 2006; 9:151-8.
8. Vasilevsky, CA,Gordon, PH, Benign Anorectal: Abscess and
fistula (eds) Bruce G W et al. The ASCRS Textbook of colon
and rectal surgery , New York, Springer Science and Business
media, 2007.
9. Williams et al. The Treatment of Anal Fistula: ACPGBI position
statement. Colorectal Disease 2007; 9 (sppl.4):18-50.
CHAPTER 14
Colostomy
Wasif Ali
INTRODUCTION
Colostomy is a surgically created opening of the large
intestine (neostoma) onto the anterior abdominal wall.
Establishment of a colostomy is an important and
sometimes a life saving surgical procedure. First
performed in 1793 by Duret, a French Surgeon,
colostomy got well established and become the
cornerstone of therapy for injures of colon and rectum
during World War II.
In order to get the best possible results, colostomy
should be considered as an important and integral
part of a surgical procedure. The possible need for
colostomy should be considered in the planning of
any intestinal procedure, both in emergency and on
elective basis. The creation of neostoma is not to be
considered an irritant and a time consuming exercise
at the end of a long operation, and should not be
handed over to the junior most member of the
surgical team to complete the operative procedure.
SELECTION OF STOMA SITE

• Great care must be taken in selecting the best site
for the stoma formation on the anterior abdominal
wall. A poorly sited stoma will cause considerable
morbidity and affect adversely the quality of life.
• Stoma should be brought out through a separate
opening in the abdominal wall, and not through
the main incision (to prevent wound infection and
incisional hernia formation).
Colostomy 209
• In general, sigmoid colostomies are sited in left

lower quadrant, and transverse colostomies in
right or left upper quadrant. The entire colon can
be mobilized to provide sufficient length to reach
any site on the abdominal wall.
• Important considerations while selecting a stoma
site are:
• Flat area of skin (for proper application of an
appliance).
• Patient’s ability to see the stoma.
• Skin crease, previous scars, bony prominences
should be avoided.
• Should not be located at the belt line.
• Site should be identified and marked preope-
ratively on the skin with patient in lying down,
sitting and standing positions.
• Pre-existing disabilities should also be taken
into account.
• Optimum site for stoma should be selected in the
outer region in relation to rectus abdomen is
muscle.
• In emergency, such careful planning may not be
possible, but on table, the best possible site, should
be selected taking into consideration all the key
points mentioned above.
• Services of enterostomal nurse should be utilized
if available while siting the stoma.
PREOPERATIVE COUNSELING
• A lot of time and effort should be put in by the
surgeon along with the enterostomal nurse in
counseling the patient before the operation with
regard to:
• Likely need for stoma
• What stoma creation would involve
• Where would stoma be sited
• Whether stoma is likely to be temporary or
permanent
• How does the stoma function
• Availability of stoma appliances
• Information regarding ostomy associations and
their supportive functions
• Quality of life with stoma.
• Visual aids (books, CDs, Videos) are useful in
explaining to the patient about the stoma care and
stoma appliances.
• Patients facing the prospect of stoma surgery
derive great benefit from meeting patients of
similar and background who have a stoma – such
a meeting could be arranged with the help of
ostomy association or with your own efforts by
inviting an earlier patient.
TYPES OF COLOSTOMIES
Different terminology is used to label a colostomy on
the basis of:
Colostomy 211
Function
• Decompression colostomy
To protect the anastomosis lower down or prior
resection of the tumor in very ill patients (Staged
procedure)
• ‘Blow hole’ stoma/Tube cecostomy
• Loop colostomy
• Diversion colostomy
• Provides complete diversion of intestinal
content.
Colonic Segment Used

• Transverse colostomy
• Sigmoid colostomy
Loop Colostomy
• A loop of colon is exteriorized and opening made
at the apex.
• Divided colostomy -Two ends of colon are
separated by a skin bridge
• Double Barrel colostomy is fashioned by bringing
a length of colon loop together by sutures before
exteriorizing the same.
In majority of cases the colostomy closes
spontaneously after spur is crushed, but may
require formal closure in some.
End Colostomy
When the proximal end of the divided colon is
brought out as a terminal stoma.
Duration of Use
• Temporary
• Permanent.
ROLE OF COLOSTOMY
• Relieves distention of colon caused by intrinsic or
extrinsic obstruction of colon, rectum and anus.
• Diverts fecal stream preparatory to resection of
obstructive lesion
• Permits resolution of inflammatory process
• Permits healing of rectal injuries
• Protects low colorectal anastomoses.
INDICATIONS
Emergency
• Large bowel obstruction – due to carcinoma,
diverticular disease, etc.
• Permits mechanical bowel preparation before
definitive bowel resection.
• Helps in resolution of sepsis.
• Distal colon/Rectal injuries.
• Anastomotic dehiscence.
• In children – Hirschsprung disease, anorectal
malformations, etc.
Colostomy 213
• It is advisable to site the colostomy well to the right

of Transverse Colon, so that during definitive
surgery, once splenic flexure is mobilized, there is
adequated colon left to restore continuity without
tension.
Elective
• Abdominoperineal resection
• Anterior resection
• Reduces the severity of sequlae of anastomatic
leak
• Colonic fistulae
• Anal surgery
• Complex fistulae – in–ano
• Sphincter repair
• Radiation proctitis
• Anal incontinence
• Intractable problems of bowel management
following spinal cord injuries.
PREOPERATIVE WORK UP
In elective cases mechanical bowel preparation and
preparative antibiotics are essential.
SURGICAL TECHNIQUE
Incision
• A midline incision is preferred for laparotomy as
it leaves areas on either side of midline available
for stoma placement.
• Loop colostomy can be made without opening the

abdomen by making a small incision at the
proposed site of stoma. Laparotomy may be
needed for sigmoid colostomy as it involves
mobilization of colon.
• Transverse loop colostomy can be done by incision
mid way between umbilicus and costal margin,
over rectus muscle and extending laterally.
• Laparoscopic approach – one port is placed
through the proposed site of stoma. The correct
bowel loop is grasped, oriented, mobilized (if
needed) and brought out through the port.
Basic Principles of Surgery

• Maintain adequate blood supply
• Preserve marginal vessels during mobilization
• Fascial opening should not be too small
• Adequate mobilization of bowel is required to be
done to bring the bowel loop on to the surface
without tension.
• Make the best possible technical effort at the time
of initial stoma formation – if correct technique is
not followed at the initial operation, it is futile to
hope that it will improve later.
Creation of Stoma
• 1 inch diameter of circular area of abdominal skin
is excised after lifting with Allies forceps.
Colostomy 215
• Subcutaneous fat need not be excised (supports

emerging stoma and prevents dead space).
• Fat is retracted to make fascia visible
• Cruciate incision is made in the rectus sheath,
about 2 cm in all direction.
• Rectus abdominis muscle fibers are split in
direction of its fibers.
• Muscle fibers are kept apart by retractors.
• Cruciate incision is made in the posterior rectus
sheath and peritoneum (Epigastric vessels if
injured may need opening of the posterior sheath
from inside the abdominal cavity for control of
bleeding).
• Opening in the abdominal wall should
accommodate two fingers.
Loop Colostomy
• Usually performed as a quick and temporary
method of relieving acute obstruction or to
provide cover for distal anastomosis
• It is best to avoid loop colostomy whenever
possible –because
• It requires a large hole in abdominal wall to
accommodate two loops of bowel.
• There are more chances of prolapse and hernia
formation.
• Absence of spur leads to difficulty in proper
collection of fecal matter.
• Accidental damage to marginal artery may occur

which may be the only blood supply available to
the anastomosis.
Steps of Operation
• Colon segment to be used to form stoma is
identified.
• Peritoneal attachments are divided to provide
sufficient length to reach anterior abdominal wall.
• Care is taken not to damage marginal artery in the
mesentery just adjacent to colonic wall.
• A catheter is passed through the opening in the
mesentery. Pull the loop out with the help of
catheter.
• Maintain orientation of colon.
• Catheter is replaced by rod (glass/plastic) to
support the loop at the level of skin.
• Main muscles are closed and dressings applied.
• Stoma is matured after making transverse incision
in the apex of the bowel loop.
• Remove rod after 5-7 days.
End Colostomy
• Adequate mobilization of descending/sigmoid
colon, if needed be taken down splenic flexure
• Colon divided at relevant site with linear stapler
or between clamps
• Check adequacy of vascular supply
Colostomy 217
• Babcock tissue forceps is passed through the

opening in the anterior abdominal wall and end
of colon grasped and brought out.
• While bringing out colon avoid twisting the colon
and damaging the vessels in the mesentery.
• Do not remove the appendices epiploic.
• End of colon should sit 2 cm above the skin.
• Edges of end of colon are freshened if needed.
• Colon is fixed to rectus sheath with 3 – 0 delayed
absorbable sutures by taking seromuscular bites.
Maturation of colostomy, i.e. suturing of mucosa
to the skin is done using interrupted delayed
absorbable sutures. Full thickness of bowel wall
and subcuticular layer of skin/full thickness of skin
are approximated.
• Spout of about 0.5-1 cm above the surface of skin
is desirable – can also be made flush with the skin.
• Lateral space between colon and abdominal wall
has to be dealt with to prevent internal herniation
– if space is large, leave it open, if small, approximate
mesocolon to the lateral abdominal wall with
absorbable sutures taking care not to injure the
ureters. Tunneling the colon to the opening in the
abdominal wall via extra peritoneal route is another
method of dealing with lateral space.
POSTOPERATIVE CARE
• Stoma appliance with a clear (transparent) bag is
placed before patient leaves the operation theater
• Inspect the stoma regularly in early postoperative

periods to look for edema, color and retraction.
• Use the services of enterostomal nurse from day 0
• Some degree of edema and duskiness is possible
during initial few days particularly if the opening
in the sheath is not of correct size.
COMPLICATIONS
Frequent (upto 25%) and can adversely affect quality
of life. Many complications are simple and managed
by enterostomal care nurse. Results of surgical
correction are often unsatisfactory.
Ischemia
• Mild ischemia is common in early postoperative
period.
• Problem is more in end stoma.
• Result of excessive fraction of marginal/mesenteric
vessels or tension in stoma because of inadequate
mobilization or too narrow fascial opening.
• Prepare the segment for use in stoma, sometime
before the end of operation so that if any ischemic
problem occurs it will be evident before the stoma
is fashioned.
• Patchy necrosis of mucosa can be managed
conservatively. It heals by primary intention.
• Complete necrosis may result if there is
constriction at the level of fascia or in fistula at the
level of fascia or stenosis.
Colostomy 219
Stenosis
• Mostly the result of postoperative ischemia/
infection
• Dilatation may be done for mild stenosis
• Severe stenosis can lead to intestinal obstruction
and may require a laparotomy for adequate
mobilization and refashioning of the stoma.
Prolapse
• Mostly seen in loop colostomy
• Result of some degree of parastomal hernia
• Best treatment is closure of colostomy. If not
advisable, colon should be devided, an end
colostomy made and distal loop closed and placed
inside the abdomen.
Retraction
• Result of poor adhesions between serosa and
subcutaneous fat
• May also indicate presence of parastomal hernia.
• If severe, may lead to intraperitoneal spillage and
require laparotomy and refashioning of colostomy.
Parastomal Hernia
• More common in obese patients and in emergency
surgeries
• Make an opening in the sheath just enough for the
emerging bowel
• Clinical and radiological studies have found no

difference in incidence of hernia when the stoma
is brought out through the rectus muscle or more
laterally.
Obstruction
• Results from stenosis of stoma, parastomal hernia,
adhesions and recurrent disease.
• Retrograde contrast study helpful in demon-
strating the cause.
Fistula
• Inadvertent full thickness placement of suture
through walls of stoma loop
• Pressure necrosis at skin level from the tight fitting
bag or recurrent disease
• Laparotomy and reallocation of stoma is invariably
required.
Other Complications
Bleeding, skin ulceration and traumatic perforation
due to irrigation tube if used.
COLOSTOMY IN OBESE PATIENTS

• It may not be possible to bring the apex of
transverse colon loop on to the anterior abdominal
Colostomy 221
wall because of short mesocolon or thick

abdominal wall
• Greater omentum is completely mobilized from
colon and middle colic vessels identified
• Incision is made in transverse mesocolon at its base
from left sde of vessels to 8 to 12 cm along the
inferior edge of pancreas, separating mesocolon
from posterior abdominal wall (inferior mesenteric
vein can be ligated if required).
• Extra length can also be gained by mobilizing
hepatic flexure
• If difficulty is still encountered, subcutaneous rod
(semimalleable) may be used to ensure adequate
diversion of fecal steam. Rod is inserted through
skin 6 to 8 cm from edge of stoma, passed in from
the anterior rectus sheath beneath the colon loop
and bought out through skin on other edge of stoma.
• If still not possible to bring out colon loop one can
go for loop ileostomy.
CLOSURE OF LOOP COLOSTOMY

Indications
When there is no longer a need to defunction the distal
bowel or after complete healing of anastomosis.
Preoperative Preparation
• Assess the colostomy site – must be healthy, non-
edematous, with no peristomal infection.
• Determine patency of distal bowel by endoscope/

contrast studies.
• Assessment of anal sphincter.
• Prepare the bowel as well as the distal segment.
• Wash or enemata
• Preoperative antibiotics.
Technical Considerations
• Simple closure is done by closing the opening in
the colon (half circumference) without excision of
bowel segment. Excision of colostomy and end to
end anastomosis is required to be done if there is
need to do a full anastomosis.
• For an intraperitoneal closure, colon loop is
mobilized fully and the colostomy is closed in
subcutaneous space in two layers. Colon is then
returned to the peritoneal cavity.
• For an extra peritoneal closure, the colon is not
mobilized, colostomy is closed and the colon is
placed in subcutaneous space. However, this
method suffers from the disadvantage that
anastomotic breakdown and dysfunction is
common in the post closure period.
• Staplers could be used as an alternative to suture
closure.
• Routine closure is easy if performed after 3 months
after stoma formation.
• Minimum time for stoma must be six weeks.
Colostomy 223
Steps of Operation
• Clean the area after removal of bag. Proximal
stoma is packed with gauze.
• Mobilization of colostomy.
• Strong silk sutures are placed at mucocutaneous
junction.
• Infiltration of adrenaline (1:100000) is done into
peristomal subcutaneous tissue.
• Incision is made all around the edge of stoma
taking 2 to 3 mm of skin.
• Anterior abdominal wall is separated from the
colon by traction on silk sutures and holding skin
edge with Allis forceps.
• Sharp dissection is done vertically down upto
fascia. Blunt dissection is avoided. If in correct
plane, bleeding is less.
• Avoid damage to colon wall. If bowel opens
accidentally, close with 3–0 delayed absorbable
sutures.
• Look out for omentum/ bowel in parastomal
hernia.
• Rectus sheath dissected all around for about
2.5 cm (for proper closure of sheath later).
• Enter peritoneal cavity all around and check for
adhesions with finger.
• Bring out bowel loop on to the skin so that at least
five cm of healthy bowel is seen.
• If the plane is difficult to find or loop is short and
not freely mobile – extend the skin incision and
enter the peritoneal cavity away from the stoma

and identify anatomical structures by inspection
and palpation.
Anastomosis
• Rim of skin edge is excised all around
• All scar tissue excised. Edges of colon should be
pink and bleeding
• The edges should be brought together without
tension. If not, free the bowel more thoroughly or
re-resect the edges to get floppy edges – closure
will be insecure if edges need to be pulled together
• Closure in two layers in transverse direction.
Single layer/staplers can also be used.
• Remobilize and Re–do the anastomosis if there is
tension/tearing/ischemia/hematoma.
• Check lumen by pinching through lumen with
finger and thumb – it should be at least 2 cm.
• Intraperitoneal tube drain placed near the anas-
tomosis.
Closure of Opening in the Abdominal Wall

• Sheath closed with interrupted No.1 nonabsorbable
monofilament suture.
• Wound washed, hemostasis checked.
• Skin closed over corrugated rubber drain or tube
suction drain. When contamination is gross wound
can be left open.
Colostomy 225
POSTOPERATIVE CARE
• As for all major abdominal surgery.
• Remove drain after 48 hour to 72 hours.
• Watch out for infection and breakdown of stoma.
COMPLICATIONS OF COLOSTOMY CLOSURE

• Wound infection
• Prevention – loose skin sutures / wound drain
• Treatment – remove suture and let out
collection
• Incisional hernia
• Breakdown of suture line
• Fecal fistula–discharge from wound– spontaneous
healing occurs if the distal loop is patent
• Complex inflammatory mass at closure site – needs
laparotomy, resection of stoma site and re-
anastomosis/re-establishment of stoma
• Peritonitis – needs laparotomy and re-establish-
ment of colostomy.
BIBLIOGRAPHY
1. Barron J, Fallis LS. Colostomy closure by the intraperitoneal
method. Dis Col Rect 1958; 1: 466-70.
2. Kelly SR, Shashidharan M, Borwell B, Tromans AM, Finnis D,
Grundy DJ. The role of intestinal stoma in patients with spinal
cord injury. Spinal Cord 1999; 37: 211-4.
3. Londono-Schimmer EE, Leong AP, Phillips RK. Life table
analysis of stomal complications following colostomy. Dis Col
Rect 1994; 37: 916-20.
4. Swinton NW, Schatman BH. Colostomy. Surg Clin North Am
1964; 44: 821-8
CHAPTER 15
Record Keeping,
Data Collection and
Audit for Individual
Surgeons
SP Kaushik
INTRODUCTION
Creation of a data bank and its management is of vital
importance for the audit of results, for improving
performance skills, betterment of patient care standards,
gaining self confidence and experience, and upgradation
of scientific approach for any individual surgeon.
Advancement of any expertise is therefore totally
dependent up on such archives. There are many contri-
butors and there is a large volume of clinical material
in a departmental or institutional setup. For an indivi-
dual surgeon, the clinical material volume is small to
start with. However, it should not be a basis for any
disappointment and discouragement and is only a
matter of time, if the records are maintained from day
one for consecutive patients that this would add up
to a reasonable number, particularly in areas of interest.
Patient related clinical data collection thus entails
keeping a detailed and honest record of each and
every case seen and treated in one’s practice.
All events and procedures including their outcome,
whether adverse or favorable, have to be logged in
for periodic analysis in order to learn meaningful
lessons and draw logical conclusions. The evidence
thus gathered forms the basis of betterment of clinical
approach and the appropriate practices in a given set
up and environment. In the present era, computer
based record keeping is preferable, although hand
written records (log book) still remain the essential
prerequisite for any data build up.
Record Keeping 229
THE DATA BANK

A medical record is a written documentation of patient
details. For gathering information in a comprehensive
and complete manner, it is far better to record
narrations, findings and treatment options with
subsequent outcome and/or events in a predetermined
format. For the sake of uniformity, a computerized
Proforma is any day better than a descriptive case file.
A proforma is essentially a questionnaire on which
the patient’s responses and other details are recorded.
While preparing such a proforma, one should
remember the relevance of information which is
required to be kept. The document so produced
should be simple, avoiding unnecessary details and
should define the responses clearly (preferable in a
numerical mode). External inputs may be desirable for
the preparation of the proforma. Once made, it should
not be changed and/or deviated from frequently, and
is to be used for every patient without any dropouts,
omissions and/or selections.
Every patient record should have a one time
identity registration number, subspeciality service
number, disease as well as a surgical procedure code,
either of one’s own generation or as per WHO
classification. Any simpler, alternative, self made form
of coding could always be used, provided it is
uniformly followed and decoded for analysis. Data
recording ought to be done under the following
heads –
i. Outpatient visit: All patients seen ought to have

a registration number and a written record of
their clinical details (salient points in the history
and clinical findings), clinical impression, relevant
investigations asked for and the preliminary
treatment given.
At the second or subsequent visits, all patients
need recording of any change in clinical signs and
symptoms, results of the investigations
previously asked for, provisional diagnosis and
the decisions taken by the clinician, i.e. to treat
the case as an outpatient or on inpatient basis.
ii. Emergency cases with acute illness should also
have similar records. Since most of them are
likely to be admitted, further details would be
required to be logged in on the inpatient
Proforma from time to time.
iii. The inpatient proforma has to have a more
comprehensive recording of clinical details,
reconfirming or contradicting the outpatient
findings, the investigations completed with results
and/or additional tests asked for under laboratory,
imaging, endoscopic and histopathology categories.
All special investigations and/or preoperative
interventions need to be recorded with justification
for their performance and the result obtained,
including any morbidity and mortality.
Once a working diagnosis is established, the
proposed therapeutic option should also be defined
Record Keeping 231
and recorded, justifying indications and/or points

in favour of taking a particular line of management.
The patient’s preoperative health score and
status should also be clearly defined and recorded.
iv. The operative details ought to include findings
on exploration, intraoperative investigations
performed, i.e. ultrasound, etc and the interventions
done before the final surgical procedure.
The final diagnosis may need to be revised at
surgery.
Ideally, a video recording should be made for
all procedures performed with a duplicate copy
kept with the department and the original given
to the patient.
v. The postoperative course and recovery in the ward,
occurrence and the nature of complications if any,
need to be clearly mentioned on the proforma.
In case of a mortality, the events leading to
death and their management also need to be
recorded.
All investigations done in the postoperative
period also need to be logged in.
Once the patient is discharged, his/her status
and health score has to be recorded once again.
Histopathology details and a decision, if any,
for ancillary treatment, i.e. radiotherapy and/or
chemotherapy also need to be documented.
vi. A follow up card ought to be available for each
patient and every visit has to be recorded with
relevant points in the progress of the patient.
If a decision is taken for revision surgery and/

or readmission, full details of the reason, i.e. nature
of recurrent problem and indications of re - surgery
need to be recorded.
The length of follow up also needs to be
recorded.
MANAGEMENT OF DATA
The ideal situation would be that proforma based
records are used routinely in one’s clinical practice and
all the relevant information is logged in on prospective
basis. However, knowing the ground realities, such
a practice may not be practical. The proforma based
records should then be generated on a daily, weekly
or monthly basis after the patient has been discharged,
and this material would then become available for the
prospective analysis of retrospective data.
The data collection could be made either under the
head of diagnosis or the operative procedure.
However, the best option would be to have four
major records of each patient as specified below;
i. OPD registration
ii. Clinical profile (including preoperative workup),
iii. Operative findings and procedures (including
postoperative course and outcome), and
iv. Follow up details.
The information thus gathered on all the four
records together becomes available for the clinical
care of the patient as well as for analysis of data.
Record Keeping 233
The data analysis should be done on a regular and

mandatory basis. If an opportunity becomes available
these exercises should be shared amongst coworkers,
friends and colleagues. This practice not only provides
fresh inputs but also gives an opportunity for the
inclusion of new ideas besides periodic stock
checking.
The data thus generated should be submitted to
an honest audit.
The audit defines;
i. Clinical acumenship in diagnosis
ii. Relevance of investigations done
iii. Preoperative decision making
iv. Justification for an operative intervention
v. The correctness of an operative procedure
performed
vi. Risk and benefit ratio to the patient
vii. Cause of a morbidity or a mortality
viii. How best the above could have been prevented
and has been managed and
ix. The short and long term result of surgical
intervention
Research and publications including case reports
in India are primarily based on clinical material which
is available to an individual in one’s own practice or
collectively in an institutional set up. Good experi-
mental research and/or animal experimentation
research is rare. For a clinical material based
publication or presentation, one needs to have a good
database. Although clinical material in our country is

in abundance, with a wide variety of clinical
presentations covering all the spectrum of disease
processes, very little use of this is being made by the
practitioners because of the lack of good data support.
No wonder that the majority of our publications are
suspects on the grounds of falsification and/or
manufacturing of data. The younger generation of
Indian surgeons ought to make a sincere and honest
effort in creation of data banks of their own which
can then be made available for any kind of scrutiny.
LEGAL ASPECTS OF MEDICAL RECORDS

Medical documentation (including informed consent
of the patient for treatment and/or any intervention
or procedure) has become a mandatory obligation on
part of clinicians/hospital set ups. A court of law
could ask for the presentation of such records as legal
evidence in a number of instances as per the Indian
Evidence Act, 1872 (amended in 1952 and 1961).
The Consumer Protection Act, 1986 has become
applicable to the medical practitioners as per the
Supreme Court orders dated, 1995. The database thus
generated would always speak in support of one’s
own experience. The clear and honest recording of
morbidity and mortality pertaining to a given surgical
procedure in one’s own practice would further give
credence and enhance one’s capability of defending
oneself in a court of law.
Record Keeping 235
Hence an accurate maintenance of patient records

would also fulfill the legal requirement. The data base
could also be used for;
i. Ethical monitoring of one’s clinical practice,
ii. Quality control of surgical care,
iii. Self-training and research,
iv. Evidence based medicare, and
v. For planning of relevant studies alone and or by
networking with other colleagues, departments
and institutions at home or abroad.
BIBLIOGRAPHY
1. Gupta S. Medical documentation in hospital practice. Ann Nat
Acad Med Sciences 2004; 40: 1-14.
2. Kaushik SP. Ethics in surgical practice: An Indian viewpoint.
Nat. Med. J. Ind. 2002; 15: 34-35.
3. Kaushik SP. Quality of Indian doctors: cause for concern. Glaxo
oration, (2006) National Academy of Medical Sciences (India)
annual conference at Amritsar, Oct, 2007.
4. Kaushik SP. Surgical audit: A must for superspeciality
development in India. Tropical Gastroenterol 2000; 21: 41-2.
5. Kaushik SP. Surgical complications: Ethical considerations and
social implications. Under publication
6. Kaushik SP. Surgical training in India. Nat Med J Ind 2002;
15: 282-3.
7. Kaushik SP. The superspeciality of surgical gastroenterology
in India. Gastroenterology Today 2000; 4: 58-60.
8. Mogli GD. Medical records: Organization and Management. 1st
Ed. Jaypee Brothers Medical Publishers, 2002.
9. Robin Kaushik. Indian surgical literature : The top 100 papers.
Ind Jour Surg 2006, 68, 11-6.
CHAPTER 16
Postoperative
Complications of
Surgery: Social
Consequences
and Ethical
Considerations
SP Kaushik
INTRODUCTION
Complications following surgical interventions are
indeed inevitable. For their successful management,
they become a challenge to the treating surgeon.
At the same time, these occurrence adversely affect
the patient’s psyche and also result into an increased
social and financial burden. The prevailing circums-
tances may thus generate a state of extreme mental
stress for the individual patient and his/her family.
In the larger context, the whole society gets affected
in the end.
The frequent occurrence of complications,
therefore, raises some pertinent questions relating to
the professional competence and skills of the
operating surgeon and at the same time reflect on
some very important medical, social and ethical
issues.
These aspects of surgical complications have not
been high lighted often, understood clearly or appre-
ciated very well, either by the professionals and or
social scientists alike. In the present day perspective,
there is need for them to be addressed seriously and
remedial measures taken, well in time, by the medical
fraternity, as well as by the existing medical set ups
and institutions, where such procedures are being
performed routinely. The surgical fraternity, social
scientists, administrators and political leadership can
not afford to ignore the plight of community under
these circumstances.
Postoperative Complications of Surgery 239
The immediate fall out of a complication, which

occurs during or after surgery, is prolongation of
hospital stay. There is resultant increase in financial
expenses, and increased psychological and physical
stress. An effort has been made in the present
communication, to look into details, some of these
aspects of surgical complications.
NUMBER AND NATURE

Even though the total number of patients developing
complications after surgical procedures may remain
small, and may be considered a matter of insignificant
percentage occurrence, taken from the individual
patient’s point of view it is either 100% “YES” or 100%
“NO”. With millions of surgeries being performed
every day all over the world, the number of such
complications in its entirety, does amount to a sizable
volume of suffering humanity.
Fortunately though, many of these complications
are preventable. In a large number of cases, the main
cause of their occurrence usually turns out to be a
faulty selection of patient. A competent surgeon,
therefore, ought to be suitably selective in choosing
his or her patients for a particular surgical procedure
and thus minimize such happenings. Factors like body
physique, general condition (both mental and
physical) and capability to undergo surgical stress
needs to be assessed carefully before surgery.
The choice of a competent surgeon and his/her ability
to assess a patient’s status correctly before inter-

vention thus becomes a matter of prime importance.
CHOICE OF THE SURGEON AND THE

PLACE OF SURGERY
The surgeon concerned should have the requisite
training background, expertise and experience to take
a particular surgical procedure to its logical conclusion
resulting into a successful outcome. Another factor of
equal importance is the infrastructure support
available in the form of hospital, operating room,
facilities, equipment and a well knit team of junior
doctors and paramedics.
Once the complication has occurred, it is the test
of the surgeon’s technical skills, and his/her ability
to handle the adverse situation on a minute to minute
basis, in order to get the patient out of a crisis
situation, at the earliest. Besides self competence and
confidence, networking with other colleagues and
institutions may well be required as an important
significant input to reduce suffering.
SOCIAL IMPACT AND CONSEQUENCES

Occurrence of a complication, no doubt, affects directly
the individual patient, who has to suffer and go through
it all by his own self. But what is not realized so well,
is the fact that it also results into serious consequences
for his/her family members and the society.
As mentioned before, prolongation of hospital stay

is the most natural outcome of a complication. One of
the major fallout of that is increased loss of work days
for a working person. This does result into increased
period of ‘no earnings’ beside other problems like
leave, etc. And if the stay away period gets further
prolonged, an employed person may stand even to
loose one’s job. A longer period of stay away from
home, family and friends in an unfriendly
environment, also contributes significantly to
increased mental strain for the patient.
‘In absence’ arrangements are never adequate
and/or satisfactory. The stress is indeed formidable
for the immediate family members i.e., the spouse
and the children. With increasing trends of
nuclearisation of the families, one is likely to find
oneself all alone at home. This in itself may become
a reason for interruption of work for the working
spouse and in addition loss of children’s educational
activity at school.
The composite effect of loss of earnings and eating
away of one’s savings coupled with increased financial
expenses at the hospital and home, may indeed
become unbearable and is indeed an important factor
in magnifying existing worries.
In a large number of Indian families, the other
half (particularly a non-working spouse) is hardly ever
prepared to face a situation which involves prolonged
absence of the bread earner, who is indeed the
manager and head of the family. The difficulties

appear to be insurmountable when it comes to overall
management of family budget, operating bank
accounts, if any, and payment of bills, etc. In
addition, other liabilities also increase the stress
related problems.
These consequences become all the more dominant
in case of an emergency intervention, and if the need
arises for intensive care treatment. In the unfortunate
event leading to death of the patient, the money matters,
assets and liabilities added on to property problems,
if any, increase the impact of tragedy many times more.
Readjustment of life style with or without shifting of
residence to another locality or township, may make
life even more difficult for the survivors.
The above narration should make it quite clear that
the adverse effects of a surgical complication do not
remain confined to an individual patient, but also
affect his/her family members and therefore, the
society as a whole. The end result of such events is
consequential increase in health budget of the society.
In developing countries, where one is already trying
to match health needs with limited finances, the better
results of surgery, with minimal or no complications
would therefore go a long way to keep the resource
crunch within acceptable limits. The medical fraternity
must therefore, work out ‘risk reduction’ strategies,
in order to make surgical intervention, a viable, more
acceptable and less expensive treatment option.
THE SURGEON’S ROLE AND INSTITUTIONAL

RESPOSIBILITIES
Most of the patients undergoing a surgical procedure,
no matter how well-informed, are largely unaware
of the possible complications of the intervention.
A large number of them are, therefore, not prepared
to face the resultant hardships and consequences that
follow such eventualities. It is therefore, obligatory
on part of the operating surgeon to have more than
one face to face interaction with the patient and the
close family members, and explain to them in clear
words all possible consequences of the intervention.
Then only would they be well-prepared to face the
unforeseeable and the least expected problems.
It would also be advisable that all the family members
including the patient should have a clear and detailed
discussion with the surgeon regarding the possible
risks and complications of surgery beforehand.
Although complications do occur in the hands of
the best of surgeons and one must accept a minimum
rate of procedure related complications, there is
absolute need to keep a constant vigil in order to keep
their occurrence within acceptable limits.
A high rate of occurrence of complications in one’s
practice, however, does become a test of competence
for the surgeon and raises pertinent questions
regarding his/her background and training. Every
patient therefore, should have the right to know the
details of the surgeon’s background, training and
experience in the field of his or her specialization

before submitting themselves or ones near and dears
ones to any intervention by him/her. There ought to
be an opportunity to discuss every aspect of patient
care and surgeon’s capabilities frankly with the
hospital authorities beforehand.
A surgeon whose patients develop frequent and
unwanted complications may also loose his/her image
and standing in the profession. Hence it is obligatory
for a surgeon to continuously strive to reduce the
complication rate further by improving his/her
acumen, technique, by discussion amongst colleagues,
mutual consultation and support. Honest and strict
audit of one’s own results, self-appraisal and
literature review thus, becomes mandatory.
The choice and place of further treatment of a
complication, and the various available options should
be considered after due care and deliberations, before
a final plan of action is worked out. There may be
need to be conservative in treating a complication and
follow wait and watch policy, but it must be realized
that because of prolongation of hospital stay and
increased costs, a far more aggressive and invasive
approach may, at times, be justifiable in order to
hasten recovery.
In the eventuality of a higher than acceptable rate
of complications occurring in one’s practice, a surgeon
should seriously consider stopping to operate for a
while, take help from others or better train oneself
all over again with known teachers/centers for a short

period. There is no room for complacence and
personal egos. Every surgeon must have the patient
related consequences of a complication, uppermost in
his/her mind and look for appropriate remedies.
Far too frequent occurrence of complications also
reflects adversely, the reputation of the hospital,
department and/or the institutional set up, and also
exposes the possible lack of support systems.
The primary objective of any such health care centres
ought to be to alleviate suffering of humanity. Such
establishments are not required to add or increase the
burden of individuals, families and the society.
The concerned authorities therefore need to define
and implement a system of checks and counter checks.
Departmental and institutional audit of results and
performances, dos and don’ts are required to be
clearly outlined. Proper monitoring of results of
surgery by supervisory committees and appropriate
bodies ought to be activated and made effective.
Performances based reward systems, i.e. distribution
of assets, budget, and allocation of other priorities to
the different departments should be carefully worked
out in order to curb adventurism on part of
individuals. It is likely to work out as one of the
successful methods to improve overall results and
better health care. An action-oriented approach by
hospital administration could thus make all the
difference for the better.
In these days of the ‘IT’ revolution, networking

between individual surgeons, faculty, departments
and different institutions should also be available on
an ‘as and when’ required basis. An appropriate
advise to the treating surgeon, in house, if possible
from another surgeon or through internet or
telemedicine facilities could be a grate help.
Alternatively the patient may be transferred to a
better equipped institution, keeping in mind the best
interest of the suffering patient and the family.
However, one should not loose sight of the fact that
if a patient, because of an unforeseeable surgical
complication, has to be referred to another institution
or town, the consequential problems do get further
magnified for the family, i.e. unfamiliar and unknown
environment, different people, increased expenses
and significantly reduced support systems (manpower
and others). In a strange place, one may even have
to face a hostile reaction, at least in the beginning,
by the host institution and inmates, in addition to the
problems of language, board and lodging, etc.
ETHICAL CONSIDERATIONS AND PRACTICES

The ethical conduct of the surgeon has an important
bearing on the results of any surgical intervention.
The malpractice arena prevalent today includes
patients snatching, undercutting (since there are no
uniform fee structures), kick backs and reward
systems, toutism, advertising, making tall claims, false
indications of interventions, cooking up data and
running down own colleagues, etc. These practices

have a definite adverse effect on surgical outcomes
and effect patient’s best interests.
Every institution and the society, therefore, should
have an effective ethical monitoring mechanism and
committees consisting of medical experts and peers.
The committee should have the authority to oversee
the quality of surgical care being delivered by
individual surgeons and the departments. An element
of accountability ought to be introduced and
committee authorized to take appropriate action and
provide relief to the consumers.
THE ROLE OF THE SOCIETY

The society and the respective health authorities, need
to play a very proactive role in support of these
unfortunate patients, who develop unexpected
complications after surgery. All grades of well
equipped and maned health care institutions in each
state, i.e. primary, secondary and tertiary level, must
be actively involved and primed for surgical care and
if found wanting, upgraded to take care of patients
in need of surgical intervention in its entirety. At the
same time apex institutions like AIIMS, New Delhi,
PGI, Chandigarh and Sanjay Gandhi PG, Lucknow
must be established in each state of India with out
any further delay, so as to provide specialized care
to it’s population with in reachable distance and under
familiar environment.
Social and financial support systems must work,

in reality, to provide help to deserving and needy
individuals who have run into complications with the
undesirable consequences of a surgical intervention.
The health support systems should materially benefit
patients with complications in a graded manner at
surgeons, departmental, institutional, state and public
administration levels.
CONCLUSIONS
In conclusion, the society, the operating surgeon as well
as the institutions and departments under taking
surgical treatment, ought to remember that they have
the primary responsibility of any intervention being
undertaken, and that a complication sets into motion a
train of undesirable consequences, which have serious
social implications. Such situations need to be appre-
ciated, recognized early, and require expert handling.
Simultaneously the public at large must realize that
surgery is also a form of treatment, and may be the
only option in certain conditions and situations. There
is always a certain amount of risk involved with all
interventions. The surgeon’s background and expertise
should be looked into in great details and the
infrastructure and facilities available at the place where
surgery is to be performed should also be checked
in advance. All possible outcomes should be discussed
with the surgeon beforehand and last but not the least
one should always be prepared to face the unexpected.
The humane approach thus, becomes the duty of

all concerned in the management of surgical patients.
A firm commitment is required by the surgeons,
departments and the institutions offering operative
treatment for the sake of better health care.
The surgical interventions though would always
be required, but these must be carried out with
minimum of complication rates and should not result
into a significant increase in already existing burden
for the sick. The society ought to evolve ways and
means to help such patients at time of need, in order
to support them morally and financially and allow
them to avail the best surgical care, resulting in
restoration of normal health at the earliest.
BIBLIOGRAPHY
1. Bajaj JS. National standards for medical education. Ann Nat
Acad Med Scs 2006;42:85-168.
2. Beauchamp G. General surgeons and clinical ethics. Can J Surg
1998;41:451-4
3. Gupta A, Kumar S, Shailendra, Mishra MC, Kumar S. Surgical
residency program. Ind J Surg 2006;68:310-5.
4. Kaushik SP. Ethics in surgical practice: An Indian viewpoint.
Nat Med J Ind 2002;15:34-6.
5. Kaushik SP. Quality of Indian doctors: A matter of concern?
Glaxo Oration, National Academy of Med. Scs. (India) 2006-
2007.
6. Kaushik SP. Surgical Audit. Tropical gastroenterol. 2000;21:
41–42.
7. Kaushik SP. Surgical training in India. Nat Med J Ind 2002;
15:282–3.
8. Sheldon MG. Medical audit in general practice. J R Coll Gen
Pract 1982;20:1-21.
Index 251
Index
A indications for cutting
196
Acute variceal bleed 112 method of application
Ampullary neoplasms 64 203
Anal fistula methods of localization
anatomy of anal 193
sphincter 186 position of the patient
anatomy of the anal 192, 198
canal 186 steps of operation 199
assessment of anal fistula surgical options 193
190 treatment of complex/
causes of recurrent fistula high fistula in ano
190 194
classification 188
complex fistula 189
high vs low fistula
B
189 Bariatric surgery 30
clinical evaluation 191 complications 44
objectives of the contraindications 32
treatment 190 indications 31
pathology of fistula 187 age 32
surgical technique 192 body mass index 31
advancement flaps operation theater layout
197 and port placement
anesthesia 192 34
bowel preparation postoperative care 42
193, 198 preoperative work up 32
contraindications 198 steps of operation 36
fibrin glue in fistula in creation of retrogastric
ano 202 tunnel 38
identification of internal fixing of hand
opening 193 anteriorly 42
goldfinger 39 colostomy in obese

inflated balloon and patients 220
locking of hand 41 complications 218
liver retractor in fascia in fistula at the
position 37 level of fascia or
pars flaccida technique stenosis 218
36 fistula 220
withdrawal of ischemia 218
goldfinger 40 obstruction 220
surgical principle 34 parastomal hernia 219
Benign biliary stricture prolapse 219
repair in PHT 100 retraction 219
Biliary surgery 94 stenosis 219
Budd-Chiari syndrome 113 complications of
colostomy closure
225
C indications
Calot’s triangle 97 emergency 212
Cholecystectomy in portal elective 213
hypertension 96 postoperative care 217, 225
incision 97 preoperative counseling
position 97 210
steps of operation 97 preoperative work up 213
Choledochal cyst and portal role of colostomy 212
hypertension 103 selection of stoma site
Collis gastroplasty 14 208
Colostomy 207 surgical technique 213
closure of loop colostomy basic principles of
221 surgery 214
anastomosis 224 creation of stoma 214
closure of opening 224 end colostomy 216
indications 221 incision 213
preoperative loop colostomy 215
preparation 221 steps of operation 216
steps of operation 223 types of colostomies 210
technical considerations decompression
222 colostomy 211
Index 253
diversion colostomy suture closure 85
211 postoperative care 90
end colostomy 212 preoperative workup 81
loop colostomy 211 surgical techniques 81
Complications after surgical incision 82
intervenetions 238 position 81
choice of the surgeon 240 steps of operative 82
ethical consideration and division of pancreas
practices 246 84
role of the society exposure of the
247 pancreas 82
institutional resposibilities ligation of the splenic
243 vessels 83
number and nature 239 retropancreatic
place of surgery 240 dissection 83
social impact and splenopancreatectomy
consequences 240 84
surgeon’s role 243
G
D
Gastric pouch formation 17
Data bank 229 contraindications 19
Distal pancreatectomy 79 indications 19
indications 80 postoperative care 25
management of steps of operation 20
pancreatic stumps closure 25
85 drain 24
closure 89 esophagojejunostomy
conventional distal 21
pancreatectomy 86 fashioning of Roux
drains 89 loop of jejunum 20
pancreaticojejunal pouch formation 20
anastomosis 86 surgical techniques
spleen preserving incision 19
distal position of patient 19
pancreatectomy 87 GERD surgery 2
stapler closure 85 complications 10
indications 2 division of vascular

long-term results 11 branches 47
Collis gastroplasty for drain placement 49
short esophagus 13 identification of crow’s
Hill posterior feet 47
gastropexy 12 surgical principle 45
minimally invasive Laparoscopic sleeve gas-
antireflux surgery trectomy 51
12
partial fundoplications
13 M
transthoracic antireflux Management of data 232
surgery 14 Median pancreatectomy 71
postoperative care 9 advantages 73
preoperative workup 3
definition 72
surgical techniques
history 73
incision 4
indications 73
position 4
postoperative care 77
steps of operation 4
wound closure 9 postoperative pancreatic
fistulas 77
I prerequisites for median
pancreatectomy 74
Interposition graft steps of operation 74
portacaval shunt reconstruction 76
129 surgical techniques 74
Intractable ascites 113 synonyms 72
Medical records 234
L
Laparoscopic sleeve gast- P
rectomy 45
complications 51 Pancreaticoduodenal
postoperative care 50 resection 56
steps of operation 46 closure 61
application of endo- indications 57
staplers around the postoperative care 61
bougie 48 preoperative workup 57
Index 255
steps of operation 59 preparation of graft 130
surgical techniques 57 pressure
anatomical conside- measurements 135
rations 58 intraoperative problems
incision 57 121
Pelvic exenteration 159 postoperative care 122
contraindications 160 preoperative preparation
indications 160 114
postoperative care 167 results 136
postoperative side to side portacaval
complications 168 shunt 124
preoperative evaluation incision 125
160 indications 125
surgical technique 161 position 125
closure 166 postoperative care 128
incision 162 steps of operation 125
position 161 technical features 123
preparation 161 Portacaval shunts 109
steps of operation 162 Portal biliopathy 104
Portacaval shunt 111 Portal hypertension 94
closure 122 Portal vein resections 141
end to side portacaval during pancreaticoduo-
shunt 115 denectomy 142
incision 115 imaging 144
position on table 115 incision 145
steps of operation 116 morbidity and
indications 112 mortality 151
interposition graft position 145
portacaval shunt preoperative workup
129 143
closure 135 steps of operation 145
incision 130 wedge resection 148
IVC anastomosis 131 iatrogenic injuries 155
portal vein traumatic injuries 153
anastomosis 133 vein/superior mesenteric
position of patient 130 vein injury 153
postoperative care 136 Pseudomyxoma peritonei 172
R peritoneal stripping
beneath the hemidia-
Radical cytoreductive surgery phragms 177
171 sigmoid colectomy 180
assessment of complete splenectomy 178
cytoreduction 182 vaginal closure 181
complications 183 surgical technique
contraindications 173 incision 176
indications 172 position 175
preoperative preparation Splenopancreatectomy 84
174 Surgery for common bile
staging 173 duct stones 99
Gilly’s staging 173
steps of operation 176
T
antrectomy 179
cholecystectomy 179 Transduodenal resection of
colorectal anastomosis ampulla 63
181 indications 64
hepatoduodenal preoperative workup 64
ligament 179 surgical techniques
omental bursa strip anatomical
179 considerations 65
omentectomy 178 incision 65
parietal peritoneal steps of operation 66
stripping from postoperative care 69
anterior abdominal
wall 177 V
pelvic peritonectomy Variceal bleed in cirrhotics
180 112

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Operative Procedures in

Professor and Head

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Operative Procedures in Surgical Gastroenterology Volume II

First Edition: 2009

Rajneesh Kumar Singh

Avinash Kumar Tang

The first edition of the book was published in 2001

developing subspecialties, i.e. liver, biliary, pancreatic,

1. Surgery for Gastroesophageal

2. Gastric Pouch Formation .................................. 17

3. Laparoscopic Restrictive Bariatric

4. Pancreas Preserving Duodenectomy .............. 55

5. Transduodenal Resection of Ampulla .......... 63

6. Median Pancreatectomy .................................... 71

8. Biliary Surgery in Portal Hypertension ....... 93

9. Portacaval Shunt in the Treatment of

10. Portal Vein Resections and Injuries ........... 141

11. Pelvic Exenteration ........................................... 159

12. Radical Cytoreductive Surgery for

13. Surgery for Complex Anal Fistula ............... 185

14. Colostomy ........................................................... 207

15. Record Keeping, Data Collection and

16. Postoperative Complications of Surgery:

Index ...................................................................... 251

The development of the superspecialty of Surgical

a new medical science! Like neurosurgery, cardiac surgery,

is to increase the number of such committed surgeons by

surgical problems. During their practical clinical examination,

well, they should be good enough to operate upon you as and

“The woods are lovely, dark and deep

• Patient develops Barrett’s changes, especially when

• Esophageal manometry: Esophageal manometry

Fig. 1.1: Division of gastrohepatic ligament sparing hepatic

• The window is enlarged and a Penrose drain is

Fig. 1.2: Approximation of diaphragmatic crura by

placed 1 cm apart, and a space of about 1 cm is

Fig. 1.3: The stomach wraps arround the esophagus

• The sutures are passed deeply though the serosa

The patient warned first about the need to chew all

proportion of patients develop new or recurrent

Minimally Invasive Antireflux Surgery

Hill Posterior Gastropexy

junction to the abdominal cavity without tension,

Collis Gastroplasty for Short Esophagus

Fig. 1.4: Collis gastroplasty

to the esophagus similar to the approach used for the

Transthoracic Antireflux Surgery

• When panmural oesophagitis has shortened the

Several modifications of the Hunt-Lawrence pouch

Fig. 2.1: Folding of jejunum on itself,

Fig. 2.2: Linear cutting stapler in place

Fig. 2.3: Application of a purse string suture

– This is engaged with anvil in the esophagus and

Fig. 2.4: Engaged endostapler in position

Fig. 2.5: Completion of pouch

• Jejuno-jejunostomy is performed in a side-side

Fig. 2.6: Jejunojejunostomy

• Epidural or parenteral analgesics are given for